Date: 17.4.2017 / Article Rating: 4 / Votes: 722
Zach.professay.info #Animals rights essay conclusion

Recent Posts

Home >> Uncategorized >> Animals rights essay conclusion

Animals rights essay conclusion

Oct/Tue/2017 | Uncategorized








Animal Rights – Essay Sample

Animals rights essay conclusion

Write My Paper -
Animals Rights Essay Example for Free

BEST ESSAY EDUCATION - HARVARD STRATEGIES FOR ESSAY WRITING. We are proud to be a provider of the best essays you might ever need. We started this company with a genuine desire to help students, business professionals, job seekers, and every single person who struggles with writing. Every customer is a huge value and we try to rights essay conclusion, do our best to his/her satisfaction at every step of essay, working with us. If you need help writing a college essay, we have the best writers to do the animals rights conclusion job for you. You can count on essay writng us as we provide top quality services, prioritize ethics in rights essay conclusion all of our business transactions, and stand behind our guarantees. Other companies may promise a good essay, but we offer the best essays online. We want you back, and back with a friend for of book reports a long-lasting and successful cooperation. So, weЂ™ll even go out on a limb to say that we have written the best essays of essay, all time. Of course, we are much more than just an essay writing website.

We are a family, a team of essay on patriotism for my, professionals, a trustworthy writing company for all your writing needs. Animals? Prices that any students can afford though high quality is a must to us. Essay Writng? Unique papers and custom writing services by professional writers. Rights Conclusion? No Plagiarism here! The research or essay is list only your property. Animals? We do not claim any rights on the paper whatsoever. Are you ready to kick some academic ass and get started? LetЂ™s get some questions out of the essay and love for my country way first. It isnЂ™t plagiarism to buy an essay from us! All of our written work is completely original and conclusion, we write your paper to order. This means your essay will be written by professionals, and will pass any plagiarism scan.

We canЂ™t say the hybrid vehicle essay same for other companies unfortunately. Many provide pre written essays that they have sold to multiple customers. It may be cheaper to buy pre written essays, but you put yourself at risk for rights conclusion being accused of academic dishonesty. This is why we are the graduate school application essays best website to buy an essay. We always provide good college essays, so purchase them from us! Well, of course we are. But, we donЂ™t expect you to take our word for it. Animals Essay Conclusion? Check out the testimonials on our website and the writing examples we provide. List Reports? We have earned a reputation as a top essay writing service by competing with all of the companies who use low quality essay writing software to turn out poorly written papers. We achieved our popularity by competing against ourselves Ђ“ by continually improving our services and by standing by our principles of providing high quality papers to animals essay, students in essay practitioner high school, college and graduate studies. Moreover, we are the best because we employ professional writers and are proud to help both high school and university students earn great grades.

So, itЂ™s no wonder that people call us the most reliable essay writing service. If you choose an essay company that operates honestly, it is very safe to buy essays online. Our pro essay writers will always provide you with a quality papers written customly for you. Animals Rights Essay? We have a well-deserved reputation as the best essay writing service today. Just search for a review of our website. Are you thinking about hybrid vehicle your wallet and your privacy? We donЂ™t blame you! All you have to do is check out the news and you will find one more company thatЂ™s been selling customer information or playing fast and rights, loose with their debit card information. Place an order with us! YouЂ™ll not only get the best college essays ever, we will keep your personal and financial information safe and sound! We care about our customers and operate as a legal, safe, and essay writng, reliable company.

ThatЂ™s why we can proudly say that we are completely legal essay writing service. Need to Write an Essay in One Day! Is it Possible? Heck yeah it is! We can write an essay in animals rights essay one day in almost every situation.

If we canЂ™t finish your essay on essay writng time, then nobody can. We know how to write an essay fast, and retain the high quality our customers have come to animals rights, expect. DonЂ™t sit in essay nurse your dorm worrying about how to write a 3000 word essay! Send it our way and animals essay, chill out! We are happy to school essays tips, be of assistance! Your Paper Written by a Top Essay Writer. Are you worried that your writer is some guy in a basement who canЂ™t string three words together? Relax! The person writing your paper will be a successful professional with a college degree. Animals Rights Essay? In fact, most of our writers have advanced degrees. Practitioner? Your writer will have impeccable English language mastery, research skills, and the ability to turn out amazingly well-written work fast!

We check each writerЂ™s background and put them through an intense training program. Our writers are the most reliable in the industry. We Are Among The Most Trusted Writing Websites For Students. Our writing is animals rights conclusion completely original and nurse practitioner, custom written to your specifications. Your work will be delivered on time. You will be completely satisfied with the animals essay conclusion product that you receive. We are very proud to have an amazing customer service track record.

We are also proud to have received many accolades and list of book, congratulations for essay conclusion the services that we offer. A high comfort level comes from communication, of course, but it also comes from important guarantees about the practitioner products and services that BestEssay.education delivers. These include, but are not limited to: No plagiarism ever! We use TurnItIn software to check all custom writing essay and essay, paper products crafted by our exceptional writers. We have yet to find any plagiarized content.

Top Quality : We know that students need to practitioner, meet the expectations of animals essay, their instructors. So, we have a Quality Assurance team that reviews all research and writing to ensure that it is scholarly and grammatically sound. Confidentiality : We know that our customers need a private relationship with us, and we protect that at of book, all times. Revisions : We know that there may be times when a customer is not 100% thrilled with what has been delivered. Essay? We will accept requests for revisions and hybrid, happily accommodate those requests at no extra charge.

Whether you need great essays, web content, or a new resume we are here for you! Even better, weЂ™ve made placing an animals essay conclusion, order freakinЂ™ simple. Seriously, just click the button and fill out some common sense information. If you can order toilet paper from Amazon you can order a paper from us. If you do need help, there is no shame in that. This is why we have the friendliest, most helpful customer service reps on the interwebs.

Just click to chat, or do the retro thing and give us a call. Someone will help you get your order in, and answer any of your questions. Pretty sweet, huh! Of course, we have to get paid before we can start working. ThatЂ™s okay, we charge reasonable prices, and offer lots of locke essay concerning understanding book 1 summary, great discounts. To make things easy for you, we accept many different forms of payment, including debit cards and PayPal! I am delighted with the services you provide. I truly adore the papers I order from, the rights essay conclusion style o. Research, Science, 22 pages, 5 days, Sophomore. I cannot but appreciate all of your great work! I#39;ve been calling day and night with this hard t. Dissertation Introduction, Law, 31 pages, 4 days, Ph.D. Thank you for essay for my the dedication to your customers!

You#39;ve been of big help and I#39;d like to wish you. Conclusion? Essay, Literature, 5 pages, 12 hours, Junior. Many thanks for hybrid vehicle delivering a great paper to me! Such a swell research! It was a lucky day to com. Research, Education, 8 pages, 48 hours, Senior. Animals Essay? Thank you for writing my essay so fast and delivering it before the time. Essay Writng? I could not have writt. Essay, English, 14 pages, 24 hours, Freshman. Rights Essay? Great quality writing.

My research was deliveredon time, though I cannot imagine how could you m. Ian, Port Gibson, Research paper, Management, 23 pages, 3 days, Junior. Chat operators are online. Phone operators are available. With BestEssay.education all your money and personal information is safed with us! We guarantee complete confidence to list of book reports, everyone! Highly-experienced writers Absolute rate of animals rights conclusion, customerЂ™s satisfaction Specific approach to each order Option of receiving order in 6 hours Function of full refund Possible corrections upon demand Immediate communication with writer. I am delighted with the services you provide. I truly adore the papers I order from, the style o. Research, Science, 22 pages, 5 days, Sophomore.

I cannot but appreciate all of your great work! I#39;ve been calling day and night with this hard t. Dissertation Introduction, Law, 31 pages, 4 days, Ph.D. Thank you for the dedication to your customers! You#39;ve been of big help and I#39;d like to wish you. Essay, Literature, 5 pages, 12 hours, Junior. Many thanks for delivering a great paper to me! Such a swell research! It was a lucky day to com.

Research, Education, 8 pages, 48 hours, Senior. List Of Book Reports? Thank you for writing my essay so fast and delivering it before the time. I could not have writt. Essay, English, 14 pages, 24 hours, Freshman. Animals Rights Conclusion? Great quality writing.

My research was deliveredon time, though I cannot imagine how could you m. Practitioner? Ian, Port Gibson, Research paper, Management, 23 pages, 3 days, Junior.

Order Paper Writing Help 24/7 -
Animals Rights Essay Example for Free

Next Plc Profitability Report Essay. Next Plc Profitability Report Essay. Based in the UK, Next is a giant retailer with numerous exciting products such as quality clothing, accessories, home products and footwear. There are three main channels through which Next Plc. distributes its products namely NEXT Retail whose chain has more than 500 stores located in the UK and Eire, NEXT Directory which provides a catalogue for home shopping with more than 3 million active customers and Websites whereby customers from over 60 countries are served. The third man in channel is NEXT International which comprises of approximately 200 franchises located in diverse regions around the globe. NEXT Sourcing plays the role of designing, sourcing and buying branded products for the group.

Additionally, Lipsy is exclusively mandated with the role of designing and selling younger women’s fashion products developed by the group. The Group’s performance over the past financial years has indicated a continuous level of profitability. Indeed, NEXT Plc operates under a primary financial objective of animals essay, delivering sustainable growth of school application tips, earnings per share over the long term. This is an animals rights conclusion important component of increased shareholder value. There has been a consistent increase in earnings per share for the Group over the years. This has been associated with continuous increase in the share price. In this report, the profitability of NEXT Plc is analyzed (NEXT Plc Group, 2013).

The report looks at the profitability ratios relating to the Group and other important ratios affecting profitability. The report also addresses the list, competitors’ performance to conclusion, ascertain any possibility of the Group’s profits dwindling. The report will also analyze the prospects of the Group in the industries it operates to establish the possibility of personal essay nurse, continued profitability. Ratio analysis is defined as a tool applied in conducting a quantitative analysis of a company using the available financial statements of the company often released periodically say one year period. The current year numbers are used in the calculation of ratios. The outcome is animals rights essay conclusion compared with the previous years’ ratios to ascertain the progress of the company. In particular, profitability ratios are important in the calculated based on the various items of the operating entries of the school application essays tips, company for a given financial year (MorningStar, 2013). In particular, profitability ratios are important in helping determine the effectiveness with which a company utilizes the available resources in generating profits. There are numerous ratios included in the calculation of the profitability of a company such as gross profit margin, net profit margin, return on capital employed and operating profit margin. The different profitability ratios are calculated using distinct formulas as shown below. Profitability is an absolute measure.

The ratios used to measure profitability try to indicate the essay, extent to which an organization is profitable based on its business operations. Profitability ascertains the whole performance of the company. In the case of NEXT Plc, profitability indicates the extent to which the Group’s performance has been affected the various business activities during the year (MorningStar, 2013). The profits made during the year are compared with the performance of the Group during the past years. Essay And Love Country! Through the essay, profitability ratios of NEXT Plc, it is possible to determine how effective the company has been in its business operations. Comparison is also made with the previous year on the performance of the company. Based on the information obtained from ratios on profitability analysis, it is possible to establish whether the firm is headed to a positive performance in the future or not. Application Essays! Additionally, profitability ratios are important in ascertaining the level of operational effectiveness of the company. The table below represents various financial ratios and information for animals NEXT Plc for the years 2010 to essay and love for my country, 2013: Source: (MorningStar, 2013) Gross profit is the difference between cost of sales and the amount of sales revenue.

Therefore, gross profit refers to the profit before the deduction of indirect expenses. Gross profit margin refers to gross profit expressed as a percentage of the rights conclusion, revenue obtained from essay writng sales. Thus Gross Profit Margin = Gross profit * 100/ Sales revenue. From the ratios above, it is evident that NEXT Plc has continuously recorded increasing gross profit margin over the past four years (MorningStar, 2013). Indeed, the ratios indicate that the year 2010 and 2011 recorded a gross profit margin as a percentage of sales of 29.3% on the other hand; the years 2012 and 2013 recorded gross profit margin as a percentage of sales of animals, 30.4% and 31.6% respectively.

Higher gross profit margins are preferred over smaller ones. In the case of school, NEXT Plc, the gross profit margin has been rising over essay conclusion, the four years. The ratio is also high meaning that it is personal essay highly preferred by investors. The increase in gross profit margin can be attributed to the increase in animals rights essay conclusion, sales throughout the period. For instance, the financial year ended 2013 saw a sales growth of 9.5%. The growth was recorded from various channels used by the Group in selling its products.

The various channels that recorded impressive sales growth included UK full price sales which grew by graduate school application 5.2%, Clearance Tab which grew by 2.2%, Markdown sales grew by animals rights essay conclusion 0.1% and vehicle International online grew by 2.0%. There was an increase in operating profits during the animals rights, financial year ended 2013 to 25.3% indicating an increase of 1.2%. Essay On Patriotism! The actual Gross profit margin for the years 2012 and 2013 were as follows: Gross profit margin = [Gross Profit * 100]/ sales revenue. 2012 Gross Profit margin = [1045.3 * 100]/3441.1 = 30.37% 2013 Gross Profit margin = [1125.58 * 100]/3562.8 =31.58% This ratio indicates the profitability after including all the costs.

Net profit margin is the net profits expressed as a percentage of the revenue acquired from sales. Thus. Net Profit Margin = Net profit (EBIT)* 100/ Sales Revenue. This ratio shows the percentage of turnover represented by net profit. From the ratio analysis above, it is evident that the net profit margin of NEXT Plc recorded a continuous increase throughout the period under consideration. There was an increase in net profit margin of more than 10% since the year 2010. Such an conclusion impressive increase in net profit margin by more than 10% means that there was a profit of more than 10% for every 1 pound of sales. Based on the fact that the net profit margin for essay 1 summary the company has been on the increase over the past four years, it is therefore evident that NEXT Plc is a profitable firm. Animals Rights! The reasons for locke human understanding 1 summary the increase in net profit margin are similar to the reasons leading to increase in gross profit margin. Nevertheless, the increase in net profit margin is an indication that there were no unnecessary expenses incurred during the period under consideration. Rights Essay Conclusion! Therefore, the overhead expenses remained low throughout the period under consideration.

Return on Capital Employed (ROCE) This ratio represents the profit for the given year as a percentage of the essay on patriotism and love for my country, total capital employed during the rights conclusion, period under analysis. The ROCE of a company is considered favorable if it is book high. Therefore, investors prefer an increasing ROCE as it indicates continuous profitability for rights essay conclusion the company during the year under analysis. ROCE seeks to ascertain the percentage return from the total capital employed in the business. Based on ROCE, the profits of the firm are measured as a percentage of the total capital employed. This ratio also attempts to hybrid essay, establish how effective the firm is in using its assets in generating profits. As a prime ratio, ROCE provides a measure of main task management indicating a maximization of the capital employed. ROCE = [Net profit (Operating profit) * 100]/Capital employed. Essay! The return on reports capital employed for NEXT Plc shows that there was an increasing return of more than 20% since 2010. This is an indication that the company has been generating over 20 pounds for every 100 pounds of capital invested throughout the period under examination (MorningStar, 2013).

This is a ratio measuring the amount of money generated by the firm from every share of stock outstanding. The method of calculating EPS is as follows: EPS = Net Profit *100 [#of common shares outstanding]. A profitable company has an EPS which increases annually. This is exemplified by NEXT Plc which has an increasing value of animals essay conclusion, EPS throughout the four years under analysis (MorningStar, 2013). This is an indication that the company has continuously improved shareholders’ value through the numerous activities undertaken.

It is also evident that the company has a highly valued share in the stock market. This financial ratio is important in expressing the graduate school essays tips, profits earned by conclusion a company as a percentage of the total assets available. This ratio is very essential in ascertaining the profitability of the list of book, company per very pound or dollar in assets invested. Therefore, the ratio indicates how is able to generate profits without including the amount of financing obtained through leverage. A well performing company should demonstrate an increasing ability to generate more profits from the assets available. According to profitability analysis of NEXT Plc, it is animals essay evident that the company’s ROA has been growing tremendously over the past years (MorningStar, 2013). Therefore, there has been a tremendous increase in the amount of pounds generated from every pound of assets invested. This ratio measures the nurse, amount of sales generated from animals conclusion every dollar or pound worth of assets. Asset turnover is therefore obtained by nurse expressing revenue as a ratio of assets as follows: Asset turnover = Revenue/Assets. In particular, asset turnover is important for growth companies as they need to establish the extent to which their revenue is growing in animals, relation to sales.

The efficiency of a firm is measured by asset turnover. This determines how the firm is efficient in generating revenue from the assets invested. When a company has a higher asset turnover ratio are considered better as opposed to those with lower ratios. From the ratios analyzed above, it is evident that NEXT Plc has had an impressive asset turnover ratio over the past years. Personal Essay! This ratio has been averaged 1.9 meaning that the company is efficient enough with an ability to generate revenue almost twice the assets invested (NEXT Plc Group, 2013). This profitability ratio measures the net income amount obtained as a percentage of animals rights conclusion, shareholders’ equity. This ratio reveals the amount of profit earned by the company in relation to on patriotism for my country, the amount of equity contributed by shareholders as indicated in the balance sheet. Indeed, shareholders are interested in seeing that their investment is animals rights able to bring about hybrid essay profits by generating income (MorningStar, 2013). From the analysis undertaken above, it is evident that there is a very positive return accrued by the equity contributed by shareholders. A Return on Equity of over 200% is an indication that NEXT Plc is a highly profitable company.

The clothing market in the UK has in the recent past indicated a downward trend. The market has been declining at an alarming rate meaning that there are limited opportunities for clothing companies to continue making massive profits. Indeed, there is a high level of co petition in the UK clothing market to the extent that the major player in the market can no longer expect to make massive profits as it has been the case in the previous years (Giffels, 2012). Indeed, competition has particularly been enhanced by animals conclusion the high employment of technology in the production process meaning that such companies have become highly efficient in their production. Additionally, there are other textile companies that have shifted their production centers in regions with cheaper in terms of labor (NEXT Plc Group, 2013). The main players in the UK clothing market still make modest profits in spite of the many challenges facing them. Expanding the market horizons in the UK clothing market is locke essay concerning human not easy based on the fact that each company has to rights essay conclusion, strive in school tips, order to sustain its current market share.

Companies that manage to expand every by animals very minimal levels have to work very hard as this is not the easiest of things to do. There are two broad categories of clothes retailers: own-brand clothes retailers and third-party retailers. Some of the graduate school tips, major players in the UK clothing market such as Arcadia Group and Marks Spenser often self own-brand clothes. Similarly, NEXT and Gap companies also sell own-brand clothes. There are other clothes companies which deal with third party clothes. Animals Rights Conclusion! The main players in the third-party clothing include the various department stores as well as individual retailers dealing with clothes from numerous clothing manufacturers.

Indeed, there is a high level of diversity in application essays, the clothing retailing (Giffels, 2012). The sector ranges from retailers dealing with low cost clothes to those dealing with formal wear, sportswear, as well as boutiques dealing with exclusive designer clothes. The clothes retail sector is rights essay conclusion much more the same as the other retail sectors. Therefore, the UK clothing retail sector is at the middle level with major players and ample opportunities to personal practitioner, make profits. NEXT Plc’s history dates back to 1864 when J. Hepworth Son founded the company.

The company was first named Gentleman’s Tailors. The founders later decided to buy Kendalls shops in 1981 leading to the establishment of group of shops dealing with women’s wear. Animals Rights Conclusion! The acquisition of Kendalls marked the birth of school application, NEXT Plc (NEXT Plc Group, 2013). Currently; NEXT Plc sells clothes which are moderately priced and acts as a trendy street retailer. The main target consumers for NEXT Plc’s clothes are men and women within the 20-40 age brackets. The company also deals with household goods as well as financial services. The analysis of NEXT Plc’s political, economic, social and technological factors reveals a trend towards ever increasing challenges especially from animals essay competitors. Nevertheless, the company continued to register impressive performance. Marks Spencer Group is one of the essay writng, major competitors of animals rights, NEXT Plc Group. Marks Spencer is a major player in the British clothing market with over 345 department stores. The company also has over 385 food shops spread over UK.

Marks Spencer is personal essay practitioner also highly effective in regions outside the UK market. In fact, Marks Spencer is rights essay operational in essay concerning understanding, over 385 places outside the animals, UK market (Giffels, 2012). The operations of Marks Spencer are felt in more than 40 countries such as Indonesia, Russia, China, South Korea, America just to mention but a few. Reports! Marks Spencer’s departmental stores often deal with household items, food and apparel with mid prices. All the products sold by Marks Spencer have the company’s private brands such as per una, portfolio, classic or autograph. Animals Essay Conclusion! Although there are many locations globally dealing with the company’s products, approximately 90% of the sales are obtained from the domestic market in the UK. Indeed, Marks Spencer is the locke book 1 summary, leading provider of men’s and women’s clothing as well as lingerie in the UK. Marks Spencer has been able to animals essay conclusion, capture the UK clothing market owing to its long existence in the market over the past 125 years. Recent financial information reveals that MS is essay writng struggling hard in the UK market just like the other companies in the same market. The company has not been able to register serious growth rates over the past years based on the intense competition level as well as the declining economies in the UK and the global economy as a whole (MorningStar, 2013).

There is definitely a very tough future for MS in terms of growth. Essay Conclusion! The recent financial releases by MS indicate a slight growth in profit. However, there is an expected continuous decline in the coming financial years. MS has continued to record very disappointing profits from locke essay concerning understanding overseas operations. This is another serious competitor to NEXT Plc. Arcadia Group is a high street company based in UK. Indeed, it is very easy to find Arcadia store in any high street in UK. Arcadia Group is a major retailer of apparel in the UK with over 2500 stores in different parts of the UK alone. Most of these stores are in animals essay, urban areas. Arcadia Group also operates over 500 franchises located in essay for my country, more than 35 countries globally. Some of these franchises include a Topshop store located in New York.

There are various fashion chains owned by Arcadia Group such as Miss Selfridge, Dorothy Perkins, Evans, Burton and Topman as well as Topshop. Most of the retail shops owned by Arcadia sell housewares and clothing. Normally, the shops offer all the seven brands locales within various suburbs. With such an impressive record, Arcadia Group provides an intensive level of competition to NEXT Plc in the highly competitive clothing market. This is yet another serious competitor to NEXT Plc. This company’s target is Hip and animals rights essay Modish through its cheap but chic clothing designs. The main target consumers for reports the company’s clothes are men and women aged 18 to 45 years. The company also deals with children’s clothes as well as cosmetics brands developed internally.

HM has recorded fast growth and now has over 2470 stores located in rights essay, more than 35 countries. The company also provides online shopping in more than 8 countries (Giffels, 2012). Sales from nurse Germany alone account for over 20% sales making it the largest market for animals essay conclusion the company. Although the company does not own its own factories, it is able to purchase goods from various locations mainly Europe and essay concerning understanding Asia. The first store selling women’s clothes owned by the company was opened in 1947 and was named Hennes. Later on, the company bought a Men’s store called Mauritz Wildforss.

The competitive analysis of NEXT Plc is animals part of the environmental threats facing the company. The company currently faces serious threats in essay writng, terms of the animals rights, low rate of essay, growth in the UK clothing market as well as the strong competition from numerous players as discussed above. Animals Rights Essay Conclusion! NEXT Plc is trying to undertake various methods in order to ensure that it reaches its current objectives (NEXT Plc Group, 2013). Some of the decisions made by the company include offering products considered to be of high street value which are being manufactured in countries with low labor costs. In such developing countries, the company’s products are also offered at essay writng, dumping prices making the markets in rights conclusion, such countries extremely weak to cause any substantial competition. Competitive force also arise in relation to influence suppliers have on NEXT Plc. However, such influence is minimal owing to locke essay book 1 summary, the many suppliers available. The customers have substantial influence on the company the animals rights, sense that if the customers boycott the list, company’s products, there would be serious implications.

Due to the absence of item specific in clothing, customers can buy from any cloth dealer; therefore, NEXT Plc has to distinguish its products from its competitors through ways such as labeling, pricing, quality, and style. NEXT Plc faces an intensification of the already stiff competition from new market entrants. Essay! However, small players cannot pose any serious threat due to capital requirement. There are various strong players outside UK which can easily pose a major challenge to 1 summary, NEXT Plc. Some good examples of serious threats include Donna Karan and Calvin Klein whose massive resources, power and knowledge can allow them to establish serious stores in animals rights essay, UK (Giffels, 2012). Graduate Tips! The current players in the UK clothing industry are serious rivals. Animals Rights Conclusion! There are several huge clothes retailers in UK totaling to more than 25,000. When combined with other small outlets, the number is personal essay more than 45,000. The many players in the UK market try to outdo each other by being sensitive about the quality, price and service of the animals essay, products sold. Critical Analysis of personal nurse practitioner, NEXT Plc Group. In the midst of the various challenges facing NEXT Plc, profitability is a major goal for the company.

Indeed, the company’s main objective each year is the conclusion, maximization of essay writng, shareholder value. The main financial objective of NEXT Plc is on the delivery of sustained growth of EPS over the long term (NEXT Plc Group, 2013). Various strategies form the basis for the attainment of the animals rights essay conclusion, main objective for essay nurse practitioner the company. Animals! For instance, the company aims at improving the range of products provided to hybrid, the customers. The company also aims at improving the retail outlets in animals rights essay, a profitable manner. This dramatically improves the volume of graduate, sales as many customers are reached. The company also seeks to improve the number of directory customers alongside their level of expenditure throughout the regions it has stores. Additionally, NEXT Plc has been on a continuous trend towards increasing its online sales from the international consumers. This means more customers can be easily reached.

One very essential undertaking practiced by NEXT Plc is the management of rights essay conclusion, net and gross margins. This is normally undertaken through appropriate product sourcing based on efficient methods as well as through cost management and control of cost. NEXT Plc also strives to maintain its financial strength by maintaining balance sheet efficiency and secure structure of financing (NEXT Plc Group, 2013). The group is also very much serious on matters related to generation of cash for issuing increased dividends as well as share repurchases. On account of the various profitability undertakings practiced by NEXT Plc, there has been a continuous improvement in sales.

For instance, the essay writng, recent statement of trading activities during the past 26 weeks up to 27 th July, 2013, NEXT Plc registered grew by 2.3%. The period also registered impressive full price sales in comparison to the anticipated sales. This can be attributed to the reduced sales figure at the end of the season. Conclusion! The month of July saw an upsurge of sales by personal essay nurse about 3.7% in comparison to the year 2012 over a similar month. Sales volatility is a major factor affecting the future profitability of NEXT Plc. Animals Essay! Indeed, the sales of the company have continuously exhibited sales volatility. The spontaneous nature with which customers are buying products has led to the increased weekly sales volatility. Indeed, there are various short-term events which highly affect weekly variance in sales.

Some of the essay on patriotism for my country, events affecting weekly changes in sales include school holidays, bank holidays, weather changes, and many other more. The recent analysis of the trends in the company’s sales and profitability indicate that consumer environment will change but on very minimal extents. Animals! The company’s sales value is anticipated to essay nurse practitioner, grow by a range of 1.5% to 3.5%. There is animals rights conclusion also a reduction in residual stock leading to reduced costs of markdown. Profitability is an locke concerning understanding essential component of a firm’s existence. Animals Rights Conclusion! Therefore, a firm which does not make profits does not create any value to essay writng, the shareholders who are the actual owners and/or directors. Profitability ratios are very essential in ascertaining the prospects of the company in fulfilling the objectives of the shareholders. Furthermore, profitability enables a firm to pursue numerous goals such as expansion.

NEXT Plc is animals a company interested in recording a continuous growth of the EPS. Hybrid Essay! This is not possible without appropriate strategies to increase the profits acquired by animals rights conclusion the company. In particular, NEXT Plc has been on the forefront towards increasing shareholder value through various strategies aimed at increasing the sales volume. Some of these strategies include expansion into numerous parts of the world, production of high quality products as well as provision of products at the lowest possible price. A detailed analysis of NEXT Plc’s profitability ratios indicates that the company is highly profitable. In terms of the nature of competition facing NEXT Plc, there is essay nurse no doubt that the conclusion, company operates in vehicle essay, a highly competitive market. Rights Conclusion! Therefore, it is graduate tips highly recommended that the company undertakes various measures that increase its level of competitiveness. The most important aspect of competition is very challenging for any company. Essay! This means that firms have to take serious measures aimed at and love for my, ensuring that they remain competitive at all times. The strategies adopted by NEXT Plc in its attempts to animals essay, remain afloat in the midst of extensive competitive pressure have been very effective as the company still continues to register impressive profitability. Therefore, profitability of NEXT Plc has been at the core of its goals.

Consequently, the nurse practitioner, company has continuously recorded improved profitability. NEXT Plc Group. (2013). Trading Statement: Sales for the 26 Weeks to 27 July 2013 . NEXT Plc. NEXT Plc Group. (2013). Annual Report and Accounts January 2013 . Rights! NEXT Plc. MorningStar. (2013).

NXT: NEXT Plc Top Competitors and Peers . Retrieved on personal essay nurse Wednesday, August 14, 2013 from http://financials.morningstar.com/competitors/industry-peer.action?t=nxtregion=gbrculture=en-US. MorningStar. Essay! (2013). NEXT Plc: Growth, Profitability and locke concerning human understanding 1 summary Financial Ratios . Retrieved on Wednesday, August 14, 2013 from http://financials.morningstar.com/ratios/r.html?t=NXTregion=GBRculture=en-US. Giffels, M. (2012). Analysis of NEXT Plc and animals rights its Environment Contents . Retrieved on Wednesday, August 14, 2013 from http://www.grin.com/en/e-book/99429/analysis-of-next-plc-and-its-environment. NEXT Plc. (2013). NEXT Plc Corporate: Business Overview . Retrieved on Wednesday, August 14, 2013 from http://www.nextplc.co.uk/about-next/business-overview.aspx. Order your paper at EssayAgents.com - Let our academic writing experts help you write a custom paper on a topic of your choice now within the shortest time possible. We are the most affordable writing service online- Click on the order now button for an instant quote. We guarantee 100% authenticity of all papers written by us. Boost your grades with our expert writing services.

Natural Environments as Determinants of health essay. Essay on Application of essay and love for my, Communication Theory in an Online Media Scandal. Alignment of HRM and Business Strategies Essay. Assignment 1: Stories of Change Essay. Comprehensive Lesson Plan for Grade 2 Essay.

2014 Uk Essay Writing and Assignment Writing Service Essay Agents.

High Quality Custom Essay Writing Service -
A Good Essay Conclusion On Animals Animal Rights Free …

3 Ways to animals rights conclusion Write Eye-Catching Resume Bullet Points For Managers. Essay And Love For My. Writing eye-catching resume bullet points for conclusion, your management resume isn#8217;t a want. But, an ABSOLUTE need. This is vehicle where many managers go wrong when writing their resumes. HR managers and recruiters look for managers who make things happen. In fact, you may too . If you#8217;re a manager who recruits and hires, then you#8217;re looking for animals essay conclusion, the #8220;movers and shakers#8221; too.

Right? So, how do you go about adding eye-catching bullet points to your resume? How to Write Eye-Catching Resume Bullet Points For Your Management Resume. Accomplishments demonstrate your skills and experience. It’s one thing to claim you can do something — it’s another to on patriotism country prove you can. First, know that resume bullet points are more often reserved for achievements. You can identify career accomplishments for your resume in different ways. Rights Conclusion. Start by looking at your past performance reviews. Ponder your most notable projects, tasks, clients, and so on. List awards and recognition you received as well.

In short, to essay writng add pizzazz to your resume bullet points is to animals rights essay conclusion put context to your accomplishments. The successes you produced for each employer. Using the below STAR formula works great: An example of a STAR statement/resume bullet point would be: Recruited to revitalize and vehicle manage an underperforming sales territory characterized by significant account attrition. (Situation) Tasked with reacquiring accounts that had left the company within the last six months. (Task) Developed contact list for animals rights essay conclusion, lapsed accounts and essays tips initiated contact with decision-makers at each company. (Action) Reacquired 22% of former customers, resulting in $872,000 in essay conclusion revenue. (Result) Quantifying your accomplishments also helps you stand out from essay concerning human understanding 1 summary, others who do the work you do. Second, realize that every bullet point in your resume needs to start with an action verb. Actions verbs are easy to conclusion identify. Nurse Practitioner. They are verbs that reflect action. So, a few example action verbs would include: These same power words are within the body of your bullet points as well. For example, #8220; Generated double-digit increases in new product revenues. Captured competitor replacement business and initiated strategic partnerships with 3 technology industry leaders.#8221; Adding a few accomplishment-specific action verbs go a long way too. For example, consider starting out your bullet points with one of these actions verbs: Third, don#8217;t settle for #8220;okay#8221; resume bullet points for your resume. [Okay] Introduced BI/analytics platform to animals rights essay the global sales team. Provided predictive sales analytics, data visualization, and qualitative CRM research. [Better] Introduced BI/analytics platform to the global sales team.

Provided predictive sales analytics, data visualization, and qualitative CRM research for $293MM worth of business development expenditures. Locke Concerning Human Understanding Book. [Best] Introduced BI/analytics platform to the global sales team. Provided predictive analytics, data visualization, and animals rights qualitative CRM research for $293MM worth of business development expenditures. Increased revenue by locke understanding 1 summary, 23.1 % in the first 90 days and essay conclusion expected to essay writng generate an animals rights incremental EBITDA of up to $39.7MM in the next year. Essay And Love Country. Okay, let#8217;s say you#8217;re not a great manager. I often hear from this from management and animals essay executive clients that I work with. #8220;My company is a bit small and doesn#8217;t enable me to produce big results.

How can I add great resume bullet points to my resume that will impress recruiters when I don#8217;t have many achievements to brag about? This can be a concern for some. And, rightfully so. I have a great way of list of book, handling this#8230; Ask yourself: What has my company accomplished with my help? Just because you didn#8217;t initiate X [project, cost savings, etc], doesn#8217;t mean you didn#8217;t contribute to the success of X. So, let#8217;s say your company recently expanded its sales to the East coast. Animals Rights Essay. But, the sales team hasn#8217;t really done much since the launch. Maybe you didn#8217;t make the decision for the expansion. Yet, you#8217;ve helped with the implementation.

For this, an achievement might look like this: Supported corporate market share growth — focused on the East coast, which includes Pennsylvania, Massachussets, and essay nurse Maryland. Worked with sales to put $12.8M into the sales pipeline and identify 250+ potential clients. Expected to add nearly $2M in revenue in rights essay conclusion 2016. See what I mean? It#8217;s not necessarily what you#8217;ve initiated, but what you#8217;ve helped your team, department, or company accomplish. Use the nurse practitioner above STAR formula to help you flesh out eye-catching resume bullet points.

Using this writing formula can help you conceptualize and animals conclusion write better resume bullet points. Do you need help writing and adding resume bullet points to human understanding book your management resume? Let#8217;s Talk. Click Here to Schedule a FREE Initial Consultation. Call Louise Garver today @ (937) 429-1332.

Resume Writing Career Coaching To Get You Interviewed Hired Faster. How to Know When It’s Time to Make a Job or Career Change. Animals Essay Conclusion. 5 Tips To Make Sure Your Executive Resume Is Ready For 2018. 7 Notables Every Executive Should Know When Working With Recruiters. LucasGroup.com Review #8220;Should You Work With Them?#8221; What Do You Do When a Recruiter Has Viewed Your LinkedIn Profile? Resume Accomplishment Examples #038; Ideas To Boost Your Resume. Hybrid. How to Develop a Personal/Professional Development Plan (PDP) Meet Louise Garver, Multi-Certified Resume Writer and Career Coach: #8220;I’ve helped thousands of frustrated job searchers to rights essay conclusion dramatically shorten the stressful time of job search and career transition to win the job of their choice at the salary they deserve.#8221; Call Louise Garver today @ (937) 429-1332.

Copyright #x000A9; 2017 Career Directions Intl, LLC.

Order Essay from Experienced Writers with Ease -
Animals Rights Essay Example for Free

cardiac case study Anesthesiology: Problem-Oriented Patient Management. CASE 15: Cardiac Tamponade. Manuel L. Fontes. Quick Links to Sections in this Chapter. Related Links in other Resources. Four days following two-vessel coronary artery bypass graft (CABG) procedure and animals rights conclusion replacement of a mitral valve, this 69-year-old woman presented with a chief complaint of shortness of graduate breath, inability to lie supine, oliguria, and overt weakness.

On examination, she appeared anxious and diaphoretic with the following vital signs: respiratory rate 38 breaths/minute, heart rate (HR) 120 beats/minute [normal sinus rhythm (NSR)], and systemic blood pressure 115/66 mm Hg. A pulmonary artery catheter (PAC) was placed and revealed: pulmonary artery (PA) pressures, 55/15 mm Hg; pulmonary artery occlusion pressure (PAOP), 14 mm Hg; central venous pressure (CVP), 23 mm Hg; and a cardiac output (CO) of 2.7 L/minute. Both the essay, prothrombin and the partial thromboplastin times were elevated. Medical Disease and on patriotism and love Differential Diagnosis What is the differential diagnosis of low cardiac output (CO) postoperatively? A. Medical Disease and Differential Diagnosis. A.1. What is the rights conclusion, differential diagnosis of low cardiac output (CO) postoperatively? CO is determined by vehicle essay, the product of stroke volume (SV) and animals conclusion heart rate (HR) during 1 minute (CO = HR x SV). Thus, a low output state can occur when SV and/or HR decrease.

Tachyarrhythmias of either ventricular or atrial origin can also cause a low output state (i.e., atrial fibrillation). To more accurately determine the etiology of essays tips a reduced SV, it is animals necessary to list explore whether there has been a change in the preload, the afterload, and/or the contractile state. Either too much preload (ventricular overdistention) or too little preload can lower the CO. Rights Conclusion? Similarly, a significant reduction in afterload (vasodilators, anesthetics, sympatholysis) or an increase in afterload (arterial resistance) can diminish SV. The latter, however, is only seen in on patriotism and love country patients with severe ventricular dysfunction whereby the heart can no longer compensate for increases in afterload. Myocardial contractility can be compromised by either direct causes (myocardial ischemia, myocardial infarction, myocardial stunning, or myocardial hibernation) and/or by indirect causes (mechanical factors as in cardiac tamponade; pharmacologic agents; and by toxins, namely, inflammatory cytokines and essay conclusion bacterial endotoxins). A combination of hemodynamic disturbances can coexist in hybrid vehicle essay the same patient. For example, a patient can have both a decrease in contractility and a reduced preload to animals rights essay account for the low output state. Correcting one problem alone may not produce the optimal hemodynamic condition.

Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. A.2. School? What is cardiac tamponade? Enumerate the rights conclusion, common etiologies of cardiac tamponade. Cardiac tamponade is personal essay nurse defined as significant compression of the heart by accumulating pericardial contents. Animals Conclusion? These include blood and clots (postcardiotomy, chamber perforation, dissecting aortic aneurysm, trauma, anticoagulant therapy), exudative effusions (malignant states, infective pericarditis, idiopathic pericarditis), nonexudative effusions (uremia, systemic lupus erythematous, rheumatoid arthritis, idiopathic, radiation), and air. Reports? How significant cardiac tamponade is depends on animals rights conclusion whether the definition is clinical versus physiologic.

That is, tamponade is a pathophysiologic continuum that on one extreme may be clinically insignificant whereas on another extreme presents as a life-threatening condition requiring emergent surgical attention. Clinical tamponade is essay writng frequently associated with marked increase in animals conclusion pericardial pressure relative to intracardiac pressures (atrial and ventricular) such that SV progressively declines resulting in systemic hypotension and in cardiogenic shock. Braunwald E, Heart disease: a textbook of cardiovascular medicine 6th ed. Philadelphia: WB Saunders, 2001:1498. Fowler NO. Gabel M. Buncher CR. Cardiac tamponade: a comparison of right heart versus left heart compression. JACC 1988:12:187.

Kaplan JA, Cardiac anesthesia 3rd ed. Philadelphia: WB Saunders, 1999:847. Spodlick D. Pathophysiology of cardiac tamponade. Essay Nurse Practitioner? Chest 1998:113:1372–1378. A.3. What is the difference between acute and delayed cardiac tamponade? In the setting of cardiac surgery, cardiac tamponade can occur acutely over minutes, hours, or after a few days postoperatively. The reported incidence of acute cardiac tamponade is 0.5#37; to 5.8#37;.

The typical patient has significant chest tube output (more than 200 mL/hour) in the immediate postoperative period associated with or without hemodynamic signs of inadequate CO. Alternatively, the chest tubes may become clogged by blood clots impeding mediastinal drainage. Delayed tamponade has been arbitrarily defined as cardiac tamponade occurring greater than 5 to 7 days after pericardiotomy. The incidence is 0.3#37; to 2.6#37; and animals rights essay is often misdiagnosed because of essay writng a low index of suspicion and because the clinical signs and symptoms can be comparable to those of congestive heart failure, pulmonary embolism, and generalized fatigue (i.e., failure to thrive postoperatively). The most common culprit in delayed cardiac tamponade is anticoagulant therapy with coumadin, heparin, and/or platelet inhibiting agents.

Effusion after cardiac surgery is common. Animals Essay Conclusion? Using echocardiography, Weitzman et al. evaluated consecutive patients postoperatively and demonstrated that 103/122 (84#37;) had pericardial effusions. Vehicle Essay? Generally, effusions reach their maximum size by the tenth postoperative day and rights regress spontaneously thereafter. D'Cruz IA. Human Understanding Book 1 Summary? Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on rights essay the diagnostic role of vehicle essay echocardiography.

J Card Surg 1992:7:257–268. Nelson RM. Jeson CB. Smoot WM. Rights Conclusion? Pericardial tamponade following open-heart surgery. J Thorac Cardiovasc Surg 1969:58:510–516. Weitzman LB. Tinker WC. Kronzon I, et al.The incidence and natural history of vehicle pericardial effusions after cardiac surgery: an echocardiographic study.

Circulation 1984:69:506. A.4. How is the diagnosis of postcardiotomy cardiac tamponade made? The diagnosis of cardiac tamponade following cardiac surgery is rights conclusion often difficult and requires a high degree of clinical suspicion, proficient knowledge of vehicle pulmonary artery catheter (PAC) derived measures, physical examination, and animals essay conclusion diagnostic tools such as echocardiography and chest x-ray film. Often, the diagnosis is made in the operating room whereby evacuation of clot and blood from the mediastinum is associated with drastic improvement in hemodynamics. Relying on one modality alone for list of book diagnosis can lead to inaccurate management decisions and increase patient morbidity. Rights? For example, the PAC is an important device for monitoring cardiac function; however, its measures can be misleading postcardiotomy unless the clinician is cognizant of hybrid essay such limitations.

The classical teaching of equalization of diastolic blood pressures in cardiac tamponade [central venous pressure (CVP) = pulmonary artery diastolic pressure (PAD) = pulmonary artery occlusion pressure (PAOP)] is infrequently observed postoperatively because the animals conclusion, pericardium is left open. As such, blood or clot or both do not distribute around the of book reports, heart homogeneously to produce equalization of pericardial diastolic pressures. Generally, the animals essay conclusion, CVP is elevated but the PAD and the PAOP can be normal, elevated, or, in some cases, reduced. With significant compression of the right heart, reduced blood flow to the pulmonary artery (PA) and to the left heart can yield lower pressures that would be inconsistent with classical tamponade physiology. Essay Writng? Russo and colleagues found that only 33#37; of patients with the animals conclusion, diagnosis of cardiac tamponade had right heart catheterization findings that reflected equalization of diastolic blood pressures. And Love For My Country? Overall, 90#37; of patients with postcardiotomy cardiac tamponade had either atypical clinical, hemodynamic, and/or echocardiographic findings. Therefore, the diagnosis of rights conclusion postoperative cardiac tamponade should be considered whenever hemodynamic deterioration is encountered, particularly when reduction in CO or blood pressure or both are not readily responsive to conventional management. Furthermore, in delayed tamponade the complaints tend to be vague and less hemodynamic data is available (i.e., PAC) to allow prompt diagnosis of tamponade.

Whenever, the patient is not progressing as expected postoperatively with some signs of end-organ dysfunction [fall in essay writng urine output and or increase blood urea nitrogen (BUN) and creatinine], an echocardiogram should be obtained to rule out cardiac tamponade. Russo A. Animals Conclusion? O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and late after cardiac surgery. Chest 1993:104:71–78. Spodlick D. Essay Writng? Pathophysiology of rights conclusion cardiac tamponade. Chest 1998:113:1372–1378. A.5. What is regional cardiac tamponade? Regional cardiac tamponade occurs when one or more cardiac chambers become compressed by blood or blood clot or both compromising forward flow.

Postcardiotomy, diastolic regional collapse of the concerning 1 summary, right atrium or the right ventricle is the most common echocardiographic finding in early cardiac tamponade. Postoperative right atrial hematoma often become localized to essay the anterior and lateral walls, whereas left atrial clots are more commonly found behind the left atrium where they become encysted in the posterior space in the oblique sinus. Selective hematoma compression of the right heart becomes less prominent in delayed tamponade as the right heart becomes adherent or tethered to the anterior chest wall. As discussed in the previous answer, the diagnosis of school tamponade is often misdiagnosed because classical features of tamponade are often absent because of uneven distribution of blood and blood clots around the animals, heart. The clinical presentation may be mistaken for congestive heart failure, acute left or right ventricular infarction, septic shock, or pulmonary embolism. Chuttani K. Pandian NG. Mohanty PK, et al.Left ventricular diastolic collapse. An echocardiographic sign of regional cardiac tamponade. Circulation 1991:83:1999–2006. Fowler NO. Gabel M. Locke Essay Concerning Human Book? Regional cardiac tamponade: a hemodynamic study.

J Am Coll Cardiol 1987:10:164–169. Hutchins GM. Rights? Isolated right atrial tamponade caused by hematoma complicating coronary artery bypass graft surgery [Letter]. Arch Pathol Lab Med 1980:104:612–614. Jadhav P. Asirvatham S. Craven P, et al.Unusual presentation of late regional cardiac tamponade after aortic surgery.

Am J Cardiac Imaging 1996:10:204–206. Kochar GS. Jocab LE. Holter MN. Right atrial impression in postoperative patients: detection by transesophageal cardiography.

J Am Coll Cardiol 1990:16:511–516. Russo A. O'Connor W. Waxman H. Atypical presentations and echocardiographic findings in patients with cardiac tamponade occurring early and vehicle essay late after cardiac surgery. Animals Rights Essay? Chest 1993:104:71–78. Sandifer DP. Gonzalez JL.

Refractory postoperative hypoxemia associated with regional cardiac tamponade and patent foramen ovale. Crit Care Med 1997:25:1608–1611. A.6. Essay Writng? What is pulsus paradoxus? What is animals essay Kussmaul's sign?

Normally, there is an inspiratory fall of less than 10 mm Hg in the arterial systolic pressure and an accompanying inspiratory fall in the venous pressure. However, a paradoxical pulse differs from the normal situation in two aspects: (a) the inspiratory fall of the arterial pressure exceeds 10 mm Hg and (b) the inspiratory venous pressure remains steady or increases (Kussmaul's sign). Echocardiographic studies of patients with cardiac tamponade by D'Cruz et al. described phasic respiratory changes whereby both left ventricular and mitral valve excursion decreased during inspiration. In contrast, right ventricular dimensions increased in association with a shifting of the interventricular septum toward the left ventricle. Of importance, pulsus paradoxus is not unique to cardiac tamponade.

The phasic respiratory changes in ventricular dimensions with exaggerated decrease in systemic systolic arterial pressure during inspiration can be present in a variety of on patriotism and love country clinical conditions whereby intrapleural pressure is significantly diminished. That is, the magnitude of paradoxical pulse is directly proportional to the inspiratory decrease of left ventricular dimension, diastolic volume, and animals rights SV. This physiologic process is often present in respiratory distress, airway obstruction, chronic obstructive pulmonary disease (COPD), and pulmonary embolism. Although a prominent feature of vehicle essay cardiac tamponade, pulsus paradoxus may not be present at all in patients with chest wall trauma, neuromuscular disease, and pneumothorax because they cannot produce sufficient negative intrapleural pressure during inspiration to produce the rights conclusion, typical changes in chamber dimension and fall in essay concerning understanding book left ventricular SV. Animals Rights Essay? Similarly, those who are receiving positive pressure mechanical ventilation (early postoperative period) and patients with severe aortic regurgitation do not exhibit pulsus paradoxus. D'Cruz IA. Overton DH. Pai GH. Pericardial complications of cardiac surgery: emphasis on the diagnostic role of and love country echocardiography.

J Card Surg 1992:7:257–268. Frey B. Rights Essay? Freezer N. Diagnostic value and for my pathophysiologic basis of pulsus paradoxus in infants and children with respiratory disease. Pediatr Pulmonol 2001:31:138–143. Jay GD. Onuma K. Davis R, et al.Analysis of physician ability in the measurement of pulsus paradoxus by sphygmomanometry. Chest 2000:118:348–352. McGregor M. Pulsus paradoxus. N Engl J Med 1979:301:480.

Tsang TS. Barnes ME. Animals Rights Essay Conclusion? Hayes SN, et al.Clinical and echocardiographic characteristics of significant pericardial effusions following cardiothoracic surgery and personal practitioner outcomes of echo-guided pericardiocentesis for management: Mayo Clinic experience, 1979#150;1998. Chest 1999:116:322–331. A.7. Describe ventricular interaction in cardiac tamponade.

Ventricular interaction is extremely important for maintenance of animals conclusion adequate cardiac performance. Under normal conditions, the average SV of the right ventricle equals the SV of the left ventricle; however, cyclical respiratory differences in left and right ventricular SV do occur. Graduate Application Essays Tips? During the inspiratory cycle, negative intrapleural pressure is generated facilitating venous return to the right heart, whereas venous return to the left heart is diminished for the following reasons: (a) lung expansion increases its reservoir for blood and conclusion (b) the increase in understanding book 1 summary right ventricular filling causes the interventricular septum to bulge leftwardly reducing left ventricular dimension and altering its compliance and filling (ventricular interaction). Animals Essay Conclusion? During exhalation, the reverse process occurs. In the case of cardiac tamponade, ventricular interaction also involves the interventricular septum but it can involve other chamber and processes depending on the etiology of the tamponade (fluid vs. clot, regional vs. global tamponade). Fundamentally, as intrapericardial content increases, it will reach a point whereby the parietal pericardium cannot stretch commensurate with the personal, rising pressure. Because of the fixed space within the rights essay conclusion, pericardium, cardiac chamber dimensions become smaller. First, the thin-walled and more compliant atriums progressively get compressed followed by the right ventricle and lastly the left ventricle.

Overall, the on patriotism, physiology of rights conclusion ventricular interaction in clinical cardiac tamponade becomes complex as the pressure-volume relationship of graduate school application essays tips mediastinal and chest structure alters with each heartbeat and from respiratory and neuroendocrine influences. Spodlick D. Animals? Pathophysiology of cardiac tamponade. Chest 1998:113:1372–1378. A.8. How is coronary blood flow affected in cardiac tamponade? In the absence of coronary artery disease, coronary blood flow is reduced in cardiac tamponade but this reduction is not sufficient to add an ischemic injury to the myocardium because there is a proportionate decrease in (a) ventricular preload (underfilled) and (b) ventricular afterload (underafterloaded). Consequently, both myocardial work and oxygen consumption are reduced. In contrast, patients with coronary artery disease may be at increased risk for myocardial ischemia or infarction or both. Reddy PS.

Curtiss EL. Otoole JD, et al.Cardiac tamponade; hemodynamic observation in man. Circulation 1978:58:265–272. Spodlick DH. Threshold of pericardial constraint: the pericardial reserve volume and auxiliary pericardial functions.

J Am Coll Cardiol 1985:6:296–299. A.9. Concerning Human Book? What are the electrocardiographic abnormalities associated with cardiac tamponade? Electrocardiographic changes may occur in the settling of cardiac tamponade. These include nonspecific ST-T wave abnormalities, low voltage QRS complex, signs of conclusion myocardial ischemia and pericarditis, and electrical alternans ( Fig. 15.1A ). Essay On Patriotism For My Country? The latter is seen in patients with large effusions and is characterized by interbeat shifts in electrical axis. Essay? This beat-to-beat alteration may be due to increased distance between the heart and the chest wall resulting in essay for my a pendulum like motion of the essay conclusion, heart. However, it has been shown that with minimal amount of pericardial fluid removal, the essay, presence of electrical alternans can be abolished while the pericardial space remains enlarged. Thus, the electrocardiographic change of electrical alternans may reflect a hemodynamic pathology rather than an anatomic abnormality.

This finding, although sensitive for cardiac tamponade, is not very specific (very few patients with tamponade present with electrical alternans). Figure 15.1. Depiction of animals essay conclusion electrical alternans in a patient with cardiac tamponade. The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography. Note the image of the left ventricle (LV) during systole and diastole. (From Longo MJ, Jaffe CC. Images in personal practitioner clinical medicine. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Figure 15.1. Depiction of electrical alternans in a patient with cardiac tamponade. The images demonstrate significant pericardial effusions (PE) obtained during transthoracic echocardiography.

Note the conclusion, image of the left ventricle (LV) during systole and diastole. Locke Essay Human Understanding? (From Longo MJ, Jaffe CC. Images in clinical medicine. Electrical alternans. N Engl J Med 1999;341:2060, with permission.) Fox JJ. Animals Conclusion? McHarg JL. Gilmour RF Jr. Ionic mechanism of electrical alternans. On Patriotism Country? Am J Physiol Heart Circ Physiol 2002:282:H516–530.

Kosta E. Kronzon I. Electrical alternans in cardiac tamponade. Echocardiography 2000:17:(6 Pt 1)575–576. Kronzon I. Animals Rights Essay? Cohen M. Winer H. For My Country? Contribution of echocardiography to the understanding of the pathophysiology of cardiac tamponade. J Am Coll Cardiol 1983:1:1180–1182. Longo MJ. Jaffe CC. Images in clinical medicine. Rights Essay Conclusion? Electrical alternans. N Engl J Med 1999:341:2060. A.10. What roentgenographic and echocardiographic findings are noted in cardiac tamponade?

On standard anterior-posterior chest roentgenography, the cardiac silhouette may appear normal in size or extremely enlarged depending on the acuity and chronicity of the tamponade process. Graduate School Essays? Normally, the pericardial fluid amounts to 15 to 25 mL. Acute tamponade physiology can arise with as little as 150 mL of effusion, whereas chronic effusions may exceed 1,000 mL before clinical signs and animals symptoms of cardiac tamponade manifest. On chest x-ray film, the cardiac silhouette will appear widened with or without features such as obscuring of the pulmonary vessels at the hilum and a globular or water bottle configuration of the heart. Transthoracic or transesophageal echocardiography can differentiate between cardiac dysfunction arising from direct myocardial injury versus cardiac dysfunction associated with mechanical processes.

Pericardial effusions can be readily seen and essay writng semiquantitated. Likewise, pericardial blood clots can be demonstrated to compress the respective chamber. Additional echocardiographic signs observed in tamponade include (a) diminished left ventricular dimension and mitral valve excursion during inspiration, (b) shifting of the rights essay conclusion, interventricular septum toward the left ventricle, (c) changes in transvalvular (mitral and aortic) flow characteristics seen by Doppler techniques, (d) diastolic posterior motion of the right ventricular wall, and (e) in some cases, a systolic notch on the right ventricular epicardium ( Fig. 15.1B and C ). Although many of the findings of both x-ray film and echocardiogram can be suggestive of cardiac tamponade, no one sign is 100#37; sensitive and specific. Braunwald E, Heart disease: a textbook of hybrid vehicle cardiovascular medicine 6th ed. Animals Rights Conclusion? Philadelphia: WB Saunders, 2001:1490. Kaplan JA, Cardiac anesthesia 4th ed. Hybrid Vehicle? Philadelphia: WB Saunders, 1999:932, 1250.

Singh SM. Wann LS. Schuchard GH, et al.Right ventricular and right atrial collapse in patients with cardiac tamponade. Circulation 1984:70:996. A.11. What is in the differential diagnosis of postcardiopulmonary bypass (post-CPB) bleeding? Significant bleeding following cardiac surgery requiring surgical exploration bring-back occurs in approximately 3#37; of cases. Often, the source of bleeding cannot be ascertained and rights its etiology is ascribed to a coagulation defect.

Procedures that require CPB are known to adversely affect the hemostatic mechanisms including vascular endothelium, fibrinolytic and coagulation factors, platelet, plasminogen, and inflammatory pathways ( Fig. 15.2 ). Under normal settings, these systems (and others yet unknown) act in concert and in locke concerning human book 1 summary opposition with one another (a) to prevent bleeding by promoting clot formation at the site of endothelial injury (procoagulant effects) and (b) to prevent or destroy clot formation (anticoagulant effects#151;either directly or indirectly via inhibitory mediators). Conclusion? Once blood elements come in contact with a nonendothelialized surface (bypass circuit), the procoagulant system becomes activated resulting in consumption of platelets, coagulation factors, and fibrinogen. The potential for postoperative bleeding will depend on personal practitioner the degree of animals rights essay activation and preexisting levels of the procoagulants as well as other factors such as the duration of CPB, systemic hypothermia, comorbid states (renal and liver insufficiency), type of surgery (reoperation, circulatory arrest, combined procedures), and prior or current treatment with anticoagulant (platelet inhibitors, coumadin, heparin). Figure 15.2. The coagulation cascade, illustrating the coagulation factors required for various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Philadelphia: JB Lippincott, 1987:1052, with permission.) Figure 15.2.

The coagulation cascade, illustrating the coagulation factors required for of book reports various screening tests. HMWK, high molecular weight kininogen; PK, prekallikrein; PL, phospholipid by platelets; PT, prothrombin time; PTT, partial thromboplastin time; TCT, thrombin clotting time; TTPL, tissue thromboplastin. (From Coleman RW, Hirsch J, Marder VJ, et al, eds. Hemostasis and thrombosis: basic principles and clinical practice, 2nd ed. Philadelphia: JB Lippincott, 1987:1052, with permission.) Platelets play an rights conclusion, important role in the coagulation process.

Once activated, they secrete several types of granules. Of Book? Granules, containing peptides such as fibrinogen, thrombospondin, factors V and animals essay conclusion VIII, and -thromboglobulin, are reduced in vehicle both number and content during CPB. Rights? Of greater importance is the loss of several membrane glycoproteins (IIb-IIIa) that interact with fibrinogen and essay nurse practitioner other cellular elements allowing for platelet conjugation and animals conclusion propagation of clot formation. Overall, postcardiotomy bleeding is list of book reports due to (a) a qualitative and a quantitative platelet defect, (b) factor deficiency, and (c) surgical bleeding. The latter can arise from either venous or arterial sources that were undetected before closure of the chest. Animals? Attentive and meticulous effort to surgical hemostasis can significantly reduce the incidence of bring-backs. Despotis GJ. Avidan MS. Hogue CW Jr. Essay? Mechanisms and attenuation of conclusion hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001:72:S1821–1831.

Harker L. Malpass TW. Branson HE. Mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective alpha-granule release. Blood 1980:56:824. Kojima T. Gando S. Morimoto Y, et al.Systematic elucidation of effects of tranexamic acid on fibrinolysis and bleeding during and after cardiopulmonary bypass surgery. Thromb Res 2001:104:301–307. Levy JH. Pharmacologic preservation of the essay writng, hemostatic system during cardiac surgery. Rights Conclusion? Ann Thorac Surg 2001:72:S1814–1820. A.12.

What is the mechanism of action of low molecular weight heparin (LMWH)? LMWHs are fragments of unfractionated heparin produced by controlled enzymatic or chemical depolymerization processes yielding chains having molecular weight of about 5,000 daltons. The parent compound is a heterogeneous mixture of polysaccharide chains with molecular weight of 3,000 to 30,000 daltons. The mechanism of action is similar for both unfractionated heparin and LMWH. School Application? Binding of the pentasaccharide to animals rights essay antithrombin (antithrombin III) results in a conformational change in antithrombin that accelerates its interaction with thrombin and factor X (factor Xa) by 1,000-fold. Personal Essay Nurse? Whereas unfractionated heparin causes a comparable inhibition of factor Xa as LMWH, its inhibition of thrombin is much more profound than LMWH. To inactivate thrombin, heparin has to bind to both antithrombin and thrombin forming a ternary complex. Heparin pentasaccharide sequences (randomly distributed along heparin chains) of 18 units or more is required for the formation of this ternary complex. Approximately 50#37; of LMWH lack the adequate length necessary for binding antithrombin and thrombin. Furthermore, only 15#37; to 25#37; of animals essay chains of list LMWH contain pentasaccharide sequences. Therefore, LMWH has greater inhibitory effect of factor Xa, whereas unfractionated heparin exerts an equipotent effect against both thrombin and factor Xa.

Lastly, both LMWH and unfractionated heparin cause release of tissue factor pathway inhibitor from vascular endothelium, which then forms a complex with and inhibits factor Xa. This complex in turn inactivates factor VIIa. Clark SC. Vitale N. Zacharias J, et al.Effect of rights essay low molecular weight heparin (fragmin) on essay writng bleeding after cardiac surgery. Ann Thorac Surg 2000:69:762–765. Danielsson A. Raub E. Lindahl U, et al.Role of rights essay conclusion ternary complexes in which heparin binds both antithrombin and proteinase, in the acceleration of the reactions between antithrombin and thrombin for factor Xa. J Biol Chem 1986:261:1546–1573. Gohlke-Barwolf C. Anticoagulation in hybrid essay valvar heart disease: new aspects and management during non-cardiac surgery.

Heart 2000:84:567–572. Harenberg J. Essay? Pharmacology of personal essay practitioner low molecular weight heparins. Semin Thomb Hemost 1990:16:12–18. Kondo NI. Maddi R. Ewenstein BM, et al.Anticoagulation and hemostasis in cardiac surgical patients.

J Card Surg 1994:9:443–461. Weitz JI. Drug therapy: low molecular weight heparins. N Engl J Med 1997:337:688–698. A.13. Describe the essay, advantages of LMWH over application essays, standard heparin therapy. There are several clinical and pharmacologic advantages of LMWH over unfractionated heparin.

The plasma half-life of LMWH is essay two to four times longer than unfractionated heparin, which undergoes a dose-dependent elimination by the liver and the kidneys. Essay On Patriotism Country? A significant amount of unfractionated heparin is bound to animals rights plasma proteins, vascular endothelium, and macrophages resulting in personal nurse less bioavailability and an unpredictable anticoagulant effect. Consequently, careful laboratory monitoring is required. Additional benefits of rights essay conclusion LMWH over unfractionated heparin include less bleeding (less platelet inhibition and less propensity for increasing microvascular permeability). Essay? Several clinical trials have demonstrated both improved efficacy and safety of LMWH over unfractionated heparin.

Of note, LMWH is not recommended in animals rights essay conclusion the setting of renal failure, and its anticoagulant activity may be measured by assaying factor Xa levels. There are, however, many different types of LMWH available in the market, each having slightly different pharmacologic effects (bioavailability, anticoagulant effect). Lastly, our understanding of the anticoagulant mechanism of LMWH continues to evolve, and, although its indications continue to broaden, there may be safety concerns that ought not to be dismissed. Alban S. Gastpar R. Plasma levels of total and essay on patriotism free tissue factor pathway inhibitor (TFPI) as individual pharmacological parameters of various heparins. Animals Essay? Thromb Haemost 2001:85:824–829.

Cohen AT. Bailey CS. Locke Concerning Human 1 Summary? Alikhan R, et al.Extended thromboprophylaxis with low molecular weight heparin reduces symptomatic venous thromboembolism following lower limb arthroplasty#151;a meta-analysis. Thromb Haemost 2001:85:940–941. Huse DM. Cummins G. Taylor DC, et al.Outpatient treatment of conclusion venous thromboembolism with low-molecular-weight heparin: an economic evaluation. Am J Managed Care 2002:8:(1Suppl)S10–16. Kleinschmidt K. Graduate Application Essays? Charles R. Pharmacology of low molecular weight heparins [Review]. Emerg Med Clin North Am 2001:19:1025–1049. A.14.

What is essay heparin-induced thrombocytopenia (HIT)? How is the diagnosis made? HIT is essay nurse practitioner a serious complication of heparin therapy that is predominantly immunemediated by animals rights essay, a binary complex of heparin and platelet factor 4 (PF4). The reaction is commonly caused by locke concerning understanding book 1 summary, an immunoglobulin (IgG) antibody that binds and animals rights conclusion activates platelets in the presence of heparin. Other immunoglobulins may also potentiate HIT. HIT exists in two forms. A benign form of HIT, type 1, is observed in approximately 10#37; to 20#37; of patients receiving unfractionated heparin. This mild form of thrombocytopenia (rarely less than 100 x 10 3 / L) occurs after 1 to graduate school tips 4 days of therapy and generally improves despite continuing heparin administration.

In contrast, type II HIT is a life-threatening condition that develops 5 to 10 days after initiating heparin therapy and rights is associated with devastating thromboembolic processes (most commonly arterial thrombosis resulting in limb ischemia, cerebrovascular events, and myocardial infarction). The platelet count falls to graduate application tips less than 50 x 10 3 / L and in severe cases to less than 5 x 10 3 / L. The incidence of HIT in patients receiving full-dose heparin ranges between 0#37; to 30#37;. Although there is no randomized prospective study looking at the true incidence of HIT, the expected incidence is estimated to be less than 5#37;. Animals Essay? Those patients who have had a previous exposure to heparin (recent and in understanding book some cases remote history) may develop HIT earlier after institution of heparin therapy as compared with those with no previous exposure. Animals Essay? The frequency of HIT is also higher in patients receiving porcine mucosal heparin compared with bovine lung heparin. The diagnosis of HIT should be entertained in any patient with a significant fall in platelet count while on heparin therapy (less than 150 x 10 3 / L or a 50#37; or greater decrease in platelet count after 5 days of therapy). The definitive diagnosis requires the following steps: (a) thrombocytopenia while on list heparin, (b) exclusion of other etiology of thrombocytopenia, (c) improvement in platelet count following cessation of heparin therapy, and (d) presence of animals rights heparin-dependent platelet antibody by essay nurse, an in vitro test.

In most cases, the diagnosis is made on essay clinical findings. Gerotziafas GT. Personal Essay Practitioner? Elalamy I. Lecrubier C, et al.The role of animals essay platelet factor 4 in platelet aggregation induced by the antibodies implicated in heparin-induced thrombocytopenia. Blood Coag Fibrinolysis 2001:12:511–520. Robitaille D. Carrier M. Graduate School Essays? Cartier R, et al.Successful management strategy for mechanical assistance and heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:1237–1240. Shea SI.

Sands JJ. Nudo SA, et al.Frequency of anti-heparin-platelet factor 4 antibodies in hemodialysis patients and correlation with recurrent vascular access thrombosis. Am J Hematol 2002:69:72–73. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Rights Conclusion? Ann Thorac Surg 2001:72:1730–1732. A.15.

What is the therapy for essay human 1 summary HIT? Because HIT type II is a potentially lethal condition, the most effective therapy is animals conclusion discontinuation of heparin. The thrombocytopenia should improve progressively. Although tempting, the on patriotism and love for my country, need for platelet transfusion is discouraged because bleeding occurs infrequently and vascular thrombosis may be potentiated. Several agents have been recommended for use in HIT. Animals Rights? These include direct thrombin inhibitors (hirudin, argatroban), LMWH, LMW heparinoid, ancrod, and antiplatelet agents. Of Book Reports? Most of these agents are not available in essay the United States for use; others are under clinical investigation. Hirudin has been extensively used in Europe with demonstrable benefit and safety. The LMWH have been shown to have cross reactivity with unfractionated heparin approaching 100#37; [C-serotonin release or by heparin-induced platelet aggregation (HIPA) assays] and should not be used in the setting of HIT unless there are demonstrable negative cross reactivity assays with standard heparin.

The ancrod is essay practitioner a defibrinogenating agent (not available in the United States) extracted from the Malayan pit viper and animals rights essay is immunologically distinct from heparin. It acts by essay writng, cleaving fibrinopeptide A from fibrinogen and its activity can be measured by assaying for plasma fibrinogen concentration. Rights Essay Conclusion? Lastly, in the setting of HIT, a synthetic analogue of prostacyclin (iloprost#151;a potent inhibitor of platelet activation) has been used successfully during cardiac surgery to prevent further reduction of platelet count. Cheng-Lai A. Essay Writng? Cardiovascular drug highlight: hirudin. Heart Dis J Cardiovasc Med 1999:1:41–49. Deitcher SR. Carman TL. Heparin-induced thrombocytopenia: natural history, diagnosis, and management.

Vasc Med 2001:6:113–119. Gill J. Essay? Kovacs MJ. Essay And Love? Successful use of danaparoid in treatment of heparin-induced thrombocytopenia during twin pregnancy. Essay? Obstet Gynecol 1997:90:(4 Pt 2)648–650. Koster A. Meyer O. Fischer T, et al.One-year experience with the platelet glycoprotein IIb/IIIa antagonist tirofiban and heparin during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II.

J Thorac Cardiovasc Surg 2001:122:1254–1255. Robitaille D. Carrier M. Reports? Cartier R, et al.Successful management strategy for mechanical assistance and animals conclusion heart transplantation in patients suffering from heparin-induced thrombocytopenia type II. J Heart Lung Transplantation 2001:20:1237–1240. Warkentin TE. Dunn GL. Cybulsky IJ. Off-pump coronary artery bypass grafting for acute heparin-induced thrombocytopenia. Ann Thorac Surg 2001:72:1730–1732. A.16. Can HIT be caused by practitioner, LMWH?

Based on rights confirmed laboratory tests, the prevalence of HIT is 2#37; for patients receiving unfractionated heparin. Essay On Patriotism And Love Country? Although the incidence of HIT is infrequent in animals rights essay conclusion the setting of LMWH, it is not zero and application tips avoidance of the latter is animals essay recommended for patients demonstrating signs of HIT while receiving unfractionated heparin. Fabris F. Luzzatto G. Stefani PM, et al.Heparin-induced thrombocytopenia [Review]. Haematologica 2000:85:72–81. Kleinschmidt K. Charles R. Pharmacology of low molecular weight heparins. Emerg Med Clin North Am 2001:19:1025–1049. Warkentin TE. Sheppard JA. Horsewood P, et al.Impact of the patient population on practitioner the risk for heparin-induced thrombocytopenia. Blood 2000:96:1703–1708.

A.17. What is the mechanism of heparin antagonism by protamine? Heparin is a large glycosaminoglycan molecule consisting of chains of alternating residues of D -glucosamine and uronic acid. It is highly negatively charged, whereas protamine is mostly positively charged. The two combine irreversibly to form a heparin-protamine complex that does not have the ability to rights conclusion bind to thrombin or factor Xa. Once neutralized, the complex of heparin and protamine is eliminated. Kimmel SE. Sekeres M. Berlin JA, et al.Mortality and adverse events after protamine administration in patients undergoing cardiopulmonary bypass. Anesth Analg 2002:94:1402–1408.

A.18. What is heparin rebound? The ACT is used to personal essay nurse confirm adequacy of heparin neutralization by protamine. Animals Rights? The concept of heparin rebound and coagulopathy following protamine reversal may occur as follows: first, heparin that is school essays tips sequestered in tissues that are poorly perfused (i.e., fat) may not undergo neutralization by protamine and second, the half-life of heparin is longer than that of protamine (45 minutes) such that as heparin is mobilized back into circulation it can inhibit thrombin formation and predispose post-CPB bleeding. Studies in which 1 mg of animals essay protamine is given per 100 units of graduate school application essays heparin (total dose) found no evidence of rights heparin rebound. Vehicle? Thus, bleeding in the postoperative cardiac surgical patient is unlikely to be from heparin rebound. Heller EL. Paul L. Rights Essay Conclusion? Anticoagulation management in a patient with an acquired antithrombin III deficiency. J Extra Corpor Technol 2001:33:245–248.

Subramaniam P. Skillington P. Tatoulis J. List Of Book Reports? Heparin-rebound in the early postoperative phase following cardiopulmonary bypass. Animals Essay? Austr N Z J Surg 1995:65:331–333. Woodman RC. Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood 1990:76:1680. A.19. How does coumadin affect the coagulation system? What is the therapy for reversing its effect? Coumadin remains the most commonly used anticoagulant agent in graduate the outpatient setting (atrial fibrillation, prosthetic valves and devices).

Its predominant pharmacodynamic effect is inhibition of synthesis of animals essay vitamin K-dependent factors (II, VII, IX, and X) in the liver and its clinical efficacy is monitored by measuring the PT or more specifically the international normalized ratio (INR). The safe or efficacy levels of either INR or PT is variable due to multiple factors, including hepatic, nutritional, drug interaction, age, and presence of other comorbid conditions. On average, it takes several days of therapy to achieve the desired INR (2 to nurse practitioner 4); consequently, administration of conclusion either LMWH or unfractionated heparin may be necessary for vehicle initiating anticoagulation. Complications occur either because of inadequate anticoagulation (thrombosis) or because of excessive anticoagulation (bleeding and animals hemorrhage). To reverse its effect, coumadin should be discontinued several days (more than 3 days) to allow levels of the essay on patriotism and love for my country, aforementioned factors to normalize. Acute reversal is achieved with FFP. Administration of vitamin K is often necessary to accelerate the synthetic process. Erban S. Initiation of animals conclusion warfarin therapy: recommendations and clinical pearls. J Thromb Thrombolysis 1999:7:145–148. Henderson MC.

White RH. Anticoagulation in the elderly. Curr Opin Pulm Med 2001:7:365–370. Horton JD. Bushwick BM. Warfarin therapy: evolving strategies in anticoagulation. Am Fam Physician 2002:65:172. Keller C. Matzdorff AC. Kemkes-Matthes B. Graduate School Application Essays Tips? Pharmacology of warfarin and clinical implication. Sem Thromb Hemost 1999:25:13–16. A.20.

What do the following measure: prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time, activated clotting time (ACT), bleeding time? PT measures the activity of the extrinsic pathway: factors I (fibrinogen), II (prothrombin), V, VII, and X ( Fig. 15.2 ). Deficiencies of factors V, VII, and X (50#37; of normal) significantly prolong the PT. Essay? Much lower concentrations of essay for my fibrinogen and animals conclusion prothrombin are required to hybrid essay prolong the PT. Activities of three of the four vitamin K-dependent factors (II, VII, IX, and X) are measured by essay conclusion, the PT. Normal values are less than 12 seconds. Activated Partial Thromboplastin Time.

Activated partial thromboplastin time (aPTT) measures the activity of the intrinsic pathway: factors XII, XI, IX, VIII, V, X, prothrombin, and tips fibrinogen ( Fig. 15.2 ). The aPTT is prolonged by animals, concentrations of essays less than 20#37; to 30#37; of these factors. Normal values are 25 to 40 seconds. Thrombin time measures the conversion of rights fibrinogen to fibrin by essay nurse, thrombin#151;the final step in the coagulation cascade ( Fig. Animals Conclusion? 15.2 ). The thrombin time is decreased in the presence of low concentrations of locke essay concerning human understanding fibrinogen and animals rights conclusion thrombin. Heparin prolongs the thrombin time, whereas coumadin has little effect. Normal values are less than 10 seconds. Activated Clotting Time.

ACT measures the general function of the graduate school tips, coagulation system. It is used primarily to measure the animals conclusion, adequacy of heparinization during CPB and protamine reversal of heparin following CPB. Prolonged ACTs may be due to heparin, low levels of coagulation factors, or thrombocytopenia. Practitioner? It is, however, not particularly specific for platelet or factor deficiencies. Animals? Normal values are 110 to 140 seconds. Bleeding time measures platelet activity, including both platelet number and aggregation.

The bleeding time becomes prolonged with platelet counts less than 50 x 10 3 / L and in the presence of inhibitors of platelet aggregation such as aspirin. Normal values are less than 5 minutes. The bleeding time has not been shown to be predictive of postoperative bleeding and is no longer performed routinely preoperatively. Barash PG, Cullen BF, Stoelting RK, Clinical anesthesia 4th ed. Personal Essay Nurse? Philadelphia: Lippincott, Williams Wilkins, 2001:219–224. Braunwald E, Fauci A, Kasper DL, et al., Harrison's principles of internal medicine 15th ed.

New York: McGraw Hill, 2001:354–358. Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and animals rights essay clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1048. A.21. How is the anticoagulant effect of LMWH monitored? There is essay on patriotism for my country no evidence that monitoring the dose improves the clinical efficacy. Conclusion? In contrast, any overdose increases the risk of hemorrhage. Because the kidneys play a significant role in the elimination of LMWH, therapeutic use of these agents should be monitored with an essay writng, antifactor Xa assay, especially in conclusion patients who have renal insufficiency, are elderly, and have clinical conditions that increase the risk of bleeding. Boneu B. de Moerloose P. How and locke essay human understanding book when to monitor a patient treated with low molecular weight heparin. Animals? Sem Thromb Hemost 2001:27:519–522.

A.22. What is a thromboelastograph? What is a Sonoclot? The thromboelastograph is an instrument that measures the development of vehicle essay blood clot viscoelastic strength over animals rights essay, time. A rotating piston is on patriotism and love suspended in a cuvette filled with heated blood. As clot formation proceeds, the rotation of the piston is affected and characteristic curves are generated ( Fig. Rights Conclusion? 15.3 ). The etiology of a coagulopathy may be obtained by analyzing these curves ( Fig. 15.4 ). The Sonoclot similarly measures the development of clot viscoelastic strength. School Application Tips? The Sonoclot piston moves vertically and measures the impedance to vibration at the tip of the probe. Sonoclot tracings obtained from platelet-rich plasma and platelet-poor plasma are shown in the Fig.

15.5 . Figure 15.3. Production of normal thromboelastogram and measured parameters. Conclusion? R, reaction time, 7 to for my 14 minutes; K value, 3 to 7 minutes; , clot formation rate, 40 degrees to 60 degrees, MA, maximum amplitude, 50 to 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Effects of animals rights essay conclusion progressive blood loss on coagulation as measured by thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.3. School Application Tips? Production of normal thromboelastogram and measured parameters.

R, reaction time, 7 to rights 14 minutes; K value, 3 to 7 minutes; , clot formation rate, 40 degrees to of book reports 60 degrees, MA, maximum amplitude, 50 to 60 mm, A60/MA, amplitude 60 minutes after MA; whole blood clot lysis index, greater than 0.85; F, whole blood clot lysis time, greater than 300 minutes. (From Tumen KJ, Spiess BD, McCathy RJ, et al. Effects of progressive blood loss on coagulation as measured by thromboelastography. Anesth Analg 1987;66:856#150;863.) Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.4. Qualitative analysis of thromboelastograms. Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and animals essay conclusion platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. Locke Essay Concerning 1 Summary? (From Saleem A, Blifeld C, Saleh SA, et al. Viscoelastic measurement of rights essay conclusion clot formation: a new test of platelet function.

Ann Clin Lab Sci 1983;13:115, with permission.) Figure 15.5. Sonoclot tracings of platelet-rich plasma (PRP) and personal essay platelet-poor plasma (PPP). A: lag period, B: primary wave, C: shoulder, D: secondary wave, E: peak, F: downward wave. (From Saleem A, Blifeld C, Saleh SA, et al. Animals Essay Conclusion? Viscoelastic measurement of clot formation: a new test of platelet function. Ann Clin Lab Sci 1983;13:115, with permission.) Avidan MS. Da Fonseca J. Parmar K, et al.The effects of aprotinin on thromboelastography with three different activators. Anesthesiology 2001:95:1169–1174.

Ellison N, Jobes DR, Effective hemostasis in the cardiac surgery Philadelphia: WB Saunders, 1988:155. Forestier F. Essay Writng? Belisle S. Animals Rights Conclusion? Contant C, et al.Reproducibility and interchangeability of the thromboelastograph, Sonoclot and Hemochron activated coagulation time in nurse cardiac surgery. Can J Anaesth 2001:48:902–910. Koster A. Rights? Hansen R. Schulz J, et al.Assessment of the of book, resonance thromboelastograph CS-3 for differentiation of coagulation disorders: a pilot in animals rights vitro investigation of essay writng simulated post-cardiopulmonary bypass coagulopathies. J Extra Corp Technol 2001:33:159–166. Koster A. Kukucka M. Fischer T, et al.Evaluation of post-cardiopulmonary bypass coagulation disorders by differential diagnosis with a multichannel modified thromboelastogram: a pilot investigation. J Extra Corp Technol 2001:33:153–158. Saleem A. Blifeld C. Saleh SA, et al.Viscoelastic measurement of animals essay conclusion clot formation: a new test of platelet function. Ann Clin Sci 1983:13:115. Vig S. Chitolie A. Bevan DH, et al.Thromboelastography: a reliable test?.

Blood Coag Fibrinolysis 2001:12:555–561. Vorweg M. List? Hartmann B. Knuttgen D, et al.Management of fulminant fibrinolysis during abdominal aortic surgery. J Cardiothorac Vasc Anesth 2001:15:764–767. A.23. How does desmopressin aid hemostasis? Desmopressin [1-deamino-8- D -arginine vasopressin (DDAVP)] increases von Willebrand's factor and factor VII activity in animals essay plasma. Personal Practitioner? von Willebrand's factor, which binds to platelets, is animals rights essay conclusion found in subendothelial tissue and is in part responsible for platelet adhesion to damaged blood vessels. DDAVP was initially shown to essay significantly decrease postoperative bleeding. Dobkowski WB. Rights Essay? Murkin JM.

A risk-benefit assessment of essay on patriotism and love for my country aprotinin in cardiac surgical procedures. Drug Safety 1998:18:21–41. Kondo NI. Maddi R. Ewenstein BM, et al.Anticoagulation and hemostasis in rights essay cardiac surgical patients. J Card Surg 1994:9:443–461. Serradeil-Le Gal C. Nonpeptide antagonists for vasopressin receptors. Pharmacology of hybrid vehicle SR 121463A, a new potent and highly selective V2 receptor antagonist.

Adv Exp Med Biol 1998:449:427–438. A.24. What is fibrinolysis? Fibrinolysis is fibrin breakdown in thrombi. Animals Conclusion? Plasmin, derived from plasminogen, is the enzyme involved in this process. Physiologic fibrinolysis involves clot remodeling and list reports removal during the healing process. Pathologic fibrinolysis occurs when fibrin in a thrombus is broken down before healing. Although elevated concentrations of plasminogen activators are found during CPB, their half-lives are very short after bypass. In cardiac surgery, fibrinolysis is a rare cause of postoperative bleeding.

Hackman T. Gascoyne CD. Naiman SC, et al.A trial of desmopressin to reduce blood loss in uncomplicated cardiac surgery. N Engl J Med 1989:321:1437. Salzman EW. Weinstein MJ. Weintraub RM, et al.Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. Animals Essay? N Engl J Med 1986:314:1402. A.25. What is aminocaproic acid?

Aminocaproic acid (Amicar) is an analogue of lysine. Its primary mechanism of action is inhibition of plasmin, resulting in less breakdown of fibrinogen, fibrin (fibrinolysis), and other clotting components. Aminocaproic acid has been effective in treating coagulopathy in the setting of heart surgery, portocaval shunts, hematologic disorders such as aplastic anemia, abruptio placentae, hepatic cirrhosis, and neoplastic diseases. Compared with placebo, both tranexamic acid and aminocaproic acid have been shown to reduce blood loss by 30#37; to 49#37; as well as reduce homologous blood transfusion. When compared with aprotinin, in high-risk patients, high dose-Amicar has also been shown to have favorable results related to reduction of blood loss and transfusion requirement.

Considering the low cost associated with aminocaproic acid therapy (less than $12), many cardiac surgical centers use this agent routinely for uncomplicated open-heart procedures. The standard intravenous preparation and dosage for cardiac surgery include 5 to 10 g of aminocaproic acid diluted and infused over 1 hour, followed by a continuous infusion at a rate of graduate essays 1 g per hour. Higher infusion rates may be used. There are several adverse events that include thrombosis (early graft closure, myocardial ischemia and infarction), agranulocytosis, leukopenia, and thrombocytopenia. Conclusion? Although rare, bradycardia and mild reduction in blood pressure have also been reported. Levi M. Cromheecke ME. de Jonge E, et al.Pharmacological strategies to list reports decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Rights Essay? Lancet 1999:354:1940–1947. A.26. What is aprotinin? Aprotinin is a complex polypeptide molecule belonging to the family of serine protease inhibitors that is extracted from bovine lung. After intravenous administration, aprotinin undergoes rapid total extravascular distribution with a plasma half-life of approximately 150 minutes.

It is filtered by the glomeruli and reabsorbed by the proximal tubules. Essay On Patriotism For My Country? The terminal half-life is approximately 10 hours. The basis for its efficacy is rights essay not fully understood but consists of a complex activation-interaction of the following systems: kallikrein resulting in kinin generation, complement and inflammatory pathways, coagulation (intrinsic and extrinsic), fibrinolytic, angiotensin, and others not yet determined ( Fig. 15.6 ). Initial contact between blood elements and the nonendothelialized surface of the CPB circuit promote contact activation of both humoral and cellular inflammatory processes. The coagulation system may be the hybrid vehicle essay, first to be activated by contact generating factor XIIa from factor XII, which then interacts with prekallikrein and high molecular weight kininogen (HMWK) to form kallikrein as well as promote the essay conclusion, activation of the other coagulation factors. Once activated, kallikrein functions to school essays stimulate and accelerate the generation of bradykinin from HMWK, factor XIIa, angiotensin, and complement activation. Factor XIIa, in turn, also interacts with fibrinogen to animals conclusion produce plasmin ( Fig. Vehicle? 15.7 ). Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.

3, tryaslol slide library [online]. Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.6. Contact activation and the role of the kallikrein system. Factor 12, XII; activated factor 12, XIIa; high-molecular weight kininogen, HK; prekallikrein, PKK; factor 11, XI; activated factor 11, XIa. (From slide set no.

3, tryaslol slide library [online]. Rights Essay Conclusion? Bayer, 2000. Available at http://www.trasylol.com/slides.htm with permission.) Figure 15.7. Involvement of the various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and graduate school application essays tips the fibrinolytic system. C1, complement; HMW, high molecular weight. (From slide set no. 3, tryaslol slide library [online]. Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.)

Figure 15.7. Involvement of the various components of coagulation including the coagulation factors, kallikrein system, complement activation, kinin generation, angiotensin system, and the fibrinolytic system. C1, complement; HMW, high molecular weight. Animals Rights Conclusion? (From slide set no. 3, tryaslol slide library [online]. Bayer, 2000. Available at: http://www.trasylol.com/slides.htm with permission.) Aprotinin has been shown to markedly reduce the aforementioned humoral processes thereby mitigating the coagulopathy associated with CPB-related procedures. Personal Nurse Practitioner? In addition, aprotinin may reduce blood loss by preserving platelet function.

The mechanism of this relates to rights essay preservation of platelet surface glycoproteins (IIb/IIIa), which is necessary for platelet-fibrinogen interaction and clot formation. The inflammatory properties of hybrid essay aprotinin (both cellular and humoral) have been shown in animal and in some human studies; however, clinical outcome trials addressing this effect have not been conducted. Animals Conclusion? In contrast, clinical trials comparing Aprotinin to placebo and/or to Amicar have consistently shown greater efficacy related to reduction in blood loss and transfusions of blood elements. Concerns regarding prothrombotic potentials, including myocardial infarction and renal dysfunction, have since been dismissed. The infarction rate and the incidence of renal dysfunction are comparable to those of personal nurse placebo ( Table 15.1 ). Aprotinin does compete with creatinine for excretion and, in some patients, there may be a mild increase in serum creatinine. Rarely, if aprotinin is used in patients with protein C or S deficiency, they may experience life-threatening thrombotic events shortly after protamine neutralization of heparin. Another important aspect of animals rights essay conclusion aprotinin use is the type of reagent used to monitor adequacy of heparinization (ACT). Kaolin is the locke book, recommended agent to be used to assess ACT when aprotinin is used (greater than 480 seconds). If Celite is used, the ACT value should be more than 750 seconds before initiation of CPB. Aprotinin is not an antithrombotic agent, and, therefore, adequate amount of heparin must be given.

Because it is a serine protease inhibitor, it interacts with antithrombin III to inhibit the action of all intrinsic and common pathway factors resulting in prolongation of measures of coagulation such as ACT. Aprotinin has a very good safety profile but serious anaphylaxis or shock can occur. This risk is increased in patients who are reexposed to aprotinin within 6 weeks. Most of the cases reported occurred within 200 days of exposure. It is recommended that a test dose of 1 mL be given when it is possible to emergently perform cannulation for instituting bypass. Whether use of histamine antagonists or steroid lessens the rights essay, incidence is not known.

The following dosing regimen is suggested: 1 mL [10,000 kallikrein inactivator units (KIU)] test dose is administered intravenously at least 10 minutes before the list of book, loading dose, followed by close observation for rights essay signs of an allergic reaction. A loading dose of 2 million KIU should then be given over 20 to 30 minutes. An additional 2 million KIU dose is essay writng added to the priming solution. Animals Rights Essay Conclusion? The maintenance dose is a constant infusion of 500,000 KIU/hour for the duration of surgery. It may be beneficial and vehicle essay cost effective to animals conclusion continue the infusion of the remaining amount of the drug while the school essays tips, patient is transferred and recovering in animals rights the ICU. A half-dose regimen has been proposed and entails reducing the previously mentioned recommendation in half. Cosgrove DM III. Heric B. Graduate School? Lytle BW, et al.Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992:54:1031–1038. Dobkowski WB.

Murkin JM. Rights Conclusion? A risk-benefit assessment of aprotinin in locke essay understanding 1 summary cardiac surgical procedures. Drug Safety 1998:18:21–41. Fujii S, Kinins V, Part B. Advances in conclusion experimental medicine and biology vol 247B: New York: Plenum Press, 1989:35–42. Hoffmann H. Personal Essay Nurse Practitioner? Siebeck M. Thetter O, et al.Aprotinin concentrations effective for the inhibition of tissue kallikrein and plasma kallikrein in vitro and in vivo. Abe K, Moriya H, Landis RC, et al., The antithrombotic and antiinflammatory mechanisms of action of aprotinin. Ann Thorac Surg 2001:72:2169–2175. Murkin JM. Attenuation of neurologic injury during cardiac surgery. Ann Thorac Surg 2001:72:S1838–1844.

Orchard MA. Goodchild CS. Prentice CRM, et al.Aprotinin reduces cardiopulmonary bypass-induced blood loss and inhibits fibrinolysis without influencing platelets. Br J Haematol 1993:85:533–541. Peters DC. Noble S. Animals Rights Conclusion? Aprotinin: an vehicle, update of animals conclusion its pharmacology and therapeutic use in open-heart surgery and coronary artery bypass surgery. Drugs 1999:57:233–260.

Serradeil-Le Gal C. Nonpeptide antagonists for school application vasopressin receptors. Pharmacology of SR 121463A, a new potent and highly selective V2 receptor antagonist. Adv Exp Med Biol 1998:449:427–438. Wahba A. Black G. Koksch M, et al.Aprotinin has no effect on platelet activation and rights essay conclusion adhesion during cardiopulmonary bypass. Thromb Haemost 1996:75:844–848. B. Preoperative Evaluation and essays tips Preparation. B.1. Interpret the hemodynamic findings of this patient. The patient has an adequate blood pressure; however, this appears to be maintained via compensatory mechanism including increase in both arterial resistance [systemic vascular resistance (SVR)] and HR. The PA systolic pressure is consistent with pulmonary hypertension arising most likely from chronic mitral valvular disease (either stenosis or insufficiency). Both the PAD and animals rights essay the PAOP suggest that the essay writng, left ventricular end diastolic pressure#151;a correlate of left ventricular preload#151;is within the normal limits.

Pressure measurements are more representative of the ventricle's state of compliance than the ventricle's volume status. Animals? Thus, a PAOP of 14 mm Hg could represent hypovolemia, normovolemia, or hypervolemia depending on the compliance of the left ventricle. A CVP of 23 torr is suggestive of right ventricular or biventricular dysfunction, tricuspid stenosis or insufficiency, or obstruction and compression of the right atrium. The CO is on patriotism for my inadequate. Rights Essay? The derived SV of 22 mL (CO/HR), combined with the other derangements (elevated CVP and PAOP of 14 mm Hg), strongly reflect right heart dysfunction. Taking into consideration the patient's overall presentation (physical examination and laboratory findings), the differential diagnosis includes right ventricular ischemia and or infarction, pulmonary embolism, atrial or ventricular septal defect (most likely left-to-right), and cardiac tamponade. An echocardiogram should be performed to assist in the diagnostic process and clinical management. Fontes ML. Bellows W. Ngo L et al. and McSPI Research Group.

Assessment of ventricular function in critically ill patients: limitations of locke essay understanding book 1 summary pulmonary artery catheterization. J Cardiothorac Vasc Anesth 1999:13:1–8. B.2. How would you treat the low output status of this patient? Although the HR is elevated, it may be unwise to attempt to normalize it before correcting the SV. The latter is a function of the preload, the essay, afterload, and the contractile status of the personal practitioner, myocardium. Whereas the preload of the right heart may be excessive (CVP = 23 mm Hg), the animals essay, preload of the left heart may not be adequate despite a PAOP of 14 mm Hg.

While waiting for the echocardiogram to school be performed, a fluid bolus can be attempted. If there is a positive response (i.e., the blood pressure and or the CO increase), additional fluid bolus can be administered until the limit of the preload reserve has been reached (operating on the flat end portion of the animals, Frank Starling's curve). List? In the setting of right ventricular failure, it is animals rights essay customary to fluid load the patient maintaining the CVP in on patriotism for my the 20s. It is animals rights important to note that fluid challenge alone will not improve cardiac performance without addressing the contractility and vehicle the afterload that, in this patient, appear to be deranged. Because there is no knowledge of the exact etiology of the low output state, it would be rational to institute inotropic support (initially, the choice of the inotrope is not that important despite the tachycardia). With regard to the afterload, both systemic and pulmonary afterloads are elevated. On the rights conclusion, right side, PA hypertension can be improved with the nitrossovasodilators (nitroglycerin or nitroprusside) but the associated systemic hypotension would prohibit their use. In fact, most vasodilators with the exception of nitric oxide would compromise the systemic pressures. Essay? Alternatively, an inotrope that has vasodilatory properties (phosphodiesterase inhibitors#151;milrinone or amrinone#151;or dobutamine) would be better choices. The SVR is a derived number (mean arterial pressure minus CVP divided by the CO and multiplied by a factor of 80). Animals Conclusion? It is important to identify and graduate application tips treat the cause of the altered CO (i.e., change in HR or SV) and not to react to animals rights essay conclusion changes in on patriotism and love country SVR.

For example, if the CO is low because of a rhythm issue or a reduced preload, it would be inappropriate to rights administer a vasodilator to correct the locke essay concerning, high SVR. In summary, a rational management of the hemodynamic findings presented would include administering fluid (crystalloid or blood products as indicated), giving inotropic support, obtaining an echocardiogram, and conclusion addressing the other systemic complications (pulmonary, renal, and coagulation). Fontes ML. Hines RL. Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. B.3. How would you evaluate this patient's coagulation status? A complete blood cell count and a complete coagulation panel should be performed.

Assuming that both the hematocrit and the platelet function are adequate, attention should be directed to essay on patriotism the elevated PT and the aPTT. Rights? The most obvious etiology for the existing coagulopathy is anticoagulation therapy. Personal Essay Nurse Practitioner? The patient has a prosthetic valve and animals rights it would be appropriate to surmise that she has been taking anticoagulants. The most common agent to be used 4 days after surgery is application warfarin (coumadin). This agent affects the vitamin-K dependent factors (II, VII, IX, and X) whose synthesis occurs in the liver. Measuring the PT and or the INR assesses the status of its anticoagulant effect. Why is the aPTT also elevated? This coagulation measure reflects the function of the following factors: V, VIII, IX, X, XI, XII, prothrombin, and fibrinogen. It can also be surmised that the elevated aPTT is due to anticoagulant therapy (e.g., excessive coumadin therapy, use of animals rights essay conclusion unfractionated heparin, or a combination of nurse practitioner treatment with heparin and coumadin). The latter approach is standard practice in cardiac surgery for patients requiring prolonged anticoagulation (i.e., valvular replacement) and can account for elevations of both the PT and the aPTT.

Other etiologies to consider include liver disorder, sepsis, and other hematologic dysfunction. Boneu B. de Moerloose P. Rights Essay? How and when to monitor a patient treated with low molecular weight heparin. Concerning Human Book? Semin Thromb Hemost 2001:27:519–522. Ellison N, Jobes DR, Effective hemostasis in cardiac surgery Philadelphia: WB Saunders, 1998:195. Keller C. Matzdorff AC. Kemkes-Matthes B. Pharmacology of essay conclusion warfarin and clinical implication. Semin Thromb Hemost 1999:25:13–16. B.4.

What do fresh frozen plasma (FFP) and cryoprecipitate contain? FFP contains the locke essay concerning human, labile factors V and VIII as well as the stable coagulation factors (II, VII, IX, X, XI). In addition, FFP contains other plasma proteins and lipids normally found in human plasma. Animals Essay? Cryoprecipitate is derived by thawing FFP at hybrid essay, 4°C. It contains factor VIII, von Willebrand's factor, and fibrinogen. Ellison N, Jobes DR, Effective hemostasis in rights cardiac surgery Philadelphia: WB Saunders, 1988:69. Levy JH. Montes F. Szlam F, et al.The in vitro effects of antithrombin III on the activated coagulation time in patients on heparin therapy. Anesth Analg 2000:90:1076–1079. Nuttall GA. Essay Writng? Oliver WC.

Santrach PJ, et al.Efficacy of a simple intraoperative transfusion algorithm for nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001:94:773–781. , discussion 5A#150;6A. B.5. What are the indications for transfusing FFP, platelet concentrate, and cryoprecipitate? Blood usually coagulates appropriately when coagulation factor concentrations are at least 20#37; to 30#37; of normal and when fibrinogen levels are greater than 75 mg/dL. Although laboratory values such as PT and partial thromboplastin time (PTT) may be abnormal, The American Society of Anesthesiologist Task Force on Blood Component Therapy discourages conventional use of FFP for perioperative treatment of bleeding because there are few clinical circumstances whereby coagulopathy arises from factor deficiency. Whereas massive blood replacement can produce prolongation of PT and/or PTT, the conclusion, task force states that a true dilutional coagulopathy does not ordinarily occur until more than 100#37; of the patient's blood volume has been replaced.

It supports the use of FFP in patients having vascular bleeding with PT and PTT values greater than 1.5 times the laboratory's normal value. FFP should be administrated in doses calculated to achieve a minimum of 30#37; of essay writng plasma factor concentration (i.e., 10 to 15 mL/kg of FFP). Recommended indications for FFP: Replacement of factor deficiencies. Reversal of coumadin effect. Massive blood transfusions. Treatment of antithrombin III deficiency in patients who are heparin resistant requiring systemic anticoagulation with heparin. In 1994 the rights essay, College of American Pathologists recommended platelet transfusions after CPB in patients with normal coagulation values and platelet count below 100,000/ L when major unexplained bleeding occurs.

Transfusion of one platelet concentrate will increase the platelet count by approximately 5 to 10 x 10 3 / L in the average adult. The usual therapeutic dose is one platelet concentration per 10-kg body weight. Platelet concentrate is indicated in the following: Active bleeding associated with thrombocytopenia. Massive blood transfusions.

The American Society of Anesthesiologist's Task Force on Blood Component Therapy recommends the administration of cryoprecipitate for. Prophylaxis in nonbleeding perioperative or peripartum patients with congenital fibrinogen deficiencies or von Willebrand's disease unresponsive to DDAVP (whenever possible, these decisions should be made in consultation with the patient's hematologist) Bleeding patients with von Willebrand's disease. Correction of microvascular bleeding in massively transfused patients with fibrinogen concentrations less than 80 to 100 mg/dL. One unit of cryoprecipitate per 10-kg body weight raises plasma fibrinogen concentration approximately 50 mg/dL in hybrid essay the absence of continued consumption or massive bleeding. Bleeding following cardiac surgery without demonstrable abnormalities of coagulation is not considered to be an indication for transfusion of animals rights FFP, platelets, or cryoprecipitate. American Society of Anesthesiologists. Guidelines for blood component therapy.

A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996:84:732–747. Despotis GJ. Levine V. Saleem R, et al.Use of point-of-care test in identification of personal nurse practitioner patients who can benefit from desmopressin during cardiac surgery: a randomized controlled trial. Lancet 1999:354:106–110. Dietrich W. Luth JU. Kormann J, et al.Intraoperative blood requirements and allogeneic blood transfusion in cardioanesthesia. Data analysis of 7729 patients in 12 cardiac surgical clinics. Anaesthesist 1999:48:876–883. Goodnough RL. Rutman RL.

Silberstein LEL. Guidelines for transfusion support in patients undergoing coronary artery bypass grafting. Ann Thorac Surg 1990:50:675–683. Murray DJ. Pennell BJ.

Weinstein SL, et al.Packed red cells in acute blood loss: dilutional coagulopathy as a course of surgical bleeding. Anesth Analg 1995:80:336–342. Shore-Lesserson L. Manspeizer HE. DePerio M, et al.Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Randomized controlled. Anesth Analg 1999:88:312–319. Stover EP. Siegel LC. Parks R, et al.Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study.

Institutions of the animals rights conclusion, Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998:88:327–333. Wilhelmi M. Franke U. Cohnert T, et al.Coronary artery bypass grafting surgery without the routine application of blood products: is locke concerning understanding it feasible?. Eur J Cardiothorac Surg 2001:19:657–661. B.6. What are the complications associated with blood component transfusions? Complications associated with transfusions of blood elements include transmission of infectious agents (e.g., hepatitis, HIV infection), hemolytic and nonhemolytic transfusion reactions, immunosuppression, anaphylactic or anaphylactoid reactions, and alloimmunization to platelet-specific antigens and the Rh antigen (resulting from erythrocyte contamination because they are stored at room temperature). Platelets in rights conclusion particular may contain proliferating bacteria.

Finally, in the immunosuppressed, graft-versus-host effects may occur following platelet transfusion. Ford SA. Kam PC. Baldo BA, et al.Anaphylactic or anaphylactoid reactions in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2001:15:684–688. Frere MC. Rapaille A. Bouillenne C, et al.Analysis of 516 reports of reactions after the transfusion of labile blood products. Transfusion Clin Biol 2001:8:333–342. Fresh frozen plasma: indications and risks. NIH Consensus Development Conference Statement 1985:5:(5)1.

Lacritz EM. Sullen GA. Aberle-Grasse J. And Love Country? Estimated risk of essay conclusion transmission of the human immunodeficiency virus by screened blood in essay the United States. N Engl J Med 1995:333:1721–1725. Nightingale SD. Department of Health and Human Services Advisory Committee on Blood Safety and Availability. Universal WBC reduction. Essay? Transfusion 2001:41:1306–1309. Platelet transfusion therapy.

NIH Consensus Development Conference Statement 1986:6:(7)1. Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990:30:583–590. B.7. Reports? What is the risk of acquiring HIV from blood exposure? The risk of HIV infection in the United States is 1/200,000 to 1/2,000,000 per unit transfused. However, with the implementation of donor screening tests for HIV-1 antigen, there is an expectation of preventing up to 25#37; of the window period cases (the period between viral infection and its detection by tests for the presence of antibodies). Perhaps the immunoviral agent most transmitted by blood transfusion is cytomegalovirus.

Bartlett JG. Report from IDSA: symposium on conclusion healthcare worker issues. The. Hopkins HIV Report: A Bimonthly Newsletter for Healthcare Providers 2000:12:(1)3, 8. Goodnough LT. Brecher ME. Kanter MH, et al.Transfusion medicine: first of 2 parts#151;blood transfusion. List Of Book? N Engl J Med 1999:340:438–447. Lacritz EM.

Sullen GA. Aberle-Grasse J, et al.Estimated risk of transmission of the human immunodeficiency virus by screened blood in the United States. N Engl J Med 1995:333:1721–1725. Lowe KC. Farrell K. Ferguson EM, et al.Current perceived risks of transfusion in the UK and relevance to the future acceptance of blood substitutes. Animals? Artif Cells Blood Substit Immobil Biotechnol 2001:29:179–189.

B.8. In what situation might aminocaproic acid improve hemostasis? Epsilon-aminocaproic acid (EACA) inhibits plasminogen activation by binding to plasminogen. Graduate School? It inhibits primary fibrinolysis, which is caused by excessive plasminogen activation by rights essay conclusion, endogenous plasminogen activators (e.g., urokinase, tissue-type plasminogen activator) occasionally seen in urinary tract bleeding and subarachnoid hemorrhage from an intracranial aneurysm. Primary fibrinolysis is rarely a cause of bleeding in the postcardiac surgery patient. Butterworth J. James RL. Lin YA, et al.Gender does not influence epsilon-aminocaproic acid concentrations in hybrid essay adults undergoing cardiopulmonary bypass. Anesth Analg 2001:92:1384–1390. Chauhan S. Rights? Kumar BA. Rao BH, et al.Efficacy of nurse practitioner aprotinin, epsilon aminocaproic acid, or combination in cyanotic heart disease. Ann Thorac Surg 2000:70:1308–1312.

Colman RW, Hirsh J, Marder VJ, et al., Hemostasis and thrombosis: basic principles and clinical practice 2nd ed. Philadelphia: JB Lippincott, 1987:1026. Ray MJ. O'Brien MF. Comparison of epsilon aminocaproic acid and animals essay conclusion low-dose aprotinin in cardiopulmonary bypass: efficiency, safety and cost. Ann Thorac Surg 2001:71:838–843. B.9. Assuming that she has cardiac tamponade, how would you prepare this patient for surgery?

As with any patient undergoing surgery, the following steps should be taken: first, a complete review of the patient's history, physical examination, and laboratory findings are mandated; second, key areas of concern should be identified and essay writng appropriate steps taken to address them; third, an anesthetic plan that is tailored to cardiac tamponade is devised; last, communication with the respective medical (surgeons, nurses, perfusionist, blood bank) and paramedical staff to ensure readiness and teamwork. The patient's presentation suggests that she is in some degree of respiratory distress. Initially, management should consist of supplemental oxygen, review of chest x-ray film, and assessment of arterial blood gasses. Shortness of breath and the inability to lie supine are frequent symptoms in patients having cardiac tamponade physiology and every effort should be made to provide comfort and lessen the associated emotional stress. Positive pressure ventilation should be avoided at all cost unless the rights conclusion, clinical picture indicates that the patient will have a cardiac arrest. Essay Writng? The persistent oliguria most likely reflects prerenal or renal (acute tubular necrosis) process secondary to reduced CO and the associated vasoconstrictive state. As described in the previous answer, optimization of animals rights essay hemodynamics should also improve the renal function. Locke? Whereas some may administer diuretics in this setting, such management is animals rights strongly discouraged. List Of Book Reports? The most effective management is surgical evacuation of the pericardial effusion or clot.

The hematologic issues include elevated PT and conclusion aPTT, blood loss, and the potential for further blood loss perioperatively. The coagulopathy should be corrected appropriately, the patient's hematocrit and list of book platelets should be checked and treated accordingly, and sufficient blood (four to rights six units) will be required in the room before commencing surgery. Fontes ML. Hines RL. Cardiogenic shock. Murray MJ, Coursin DB, Pearl RG, et al., Critical care medicine: perioperative management New York: Raven Press, 1997:295–306. Kirklin JK, Barratt-Boyes BG, Cardiac surgery 2nd ed. New York: Churchill Livingstone, 1993:1685. Nelson RM. Jeson CB. Smoot WM.

Pericardial tamponade following open-heart surgery. J Thorac Cardiovascular Surg 1969:58:510–516. B.10. What premedication would you prescribe? Although it is important to reduce the emotional stress preoperatively, in essay nurse the setting of cardiac tamponade it would be unwise to administer any type of anxiolytic. The most effective approach is conclusion communication with the patient. List Of Book? Often, the physical appearance and the hemodynamics can be misguiding and rights essay catastrophic consequences can arise from hybrid vehicle, premedicating patients in tamponade. A state of marked sympathoadrenal activation exists to support perfusion to animals essay conclusion vital organs. By partially blocking this compensatory effect with an anxiolytic, cardiovascular collapse may ensue and most efforts to hybrid vehicle resuscitate the patient would fail.

The chest would have to be opened emergently predisposing the patient to additional morbidity as well as mortality. C. Intraoperative Management. C.1. How would you monitor this patient during transport to the operating room? What emergency drugs would you bring with you? The patient must be under hypervigilance and vital signs must be continuously assessed including invasive monitoring of systemic blood pressure, electrocardiogram, and oxygen saturation.

In addition, emergency cardioactive and vasoactive drugs should be available during transport: Oxygen: increase the F IO 2 as needed. Animals Rights Essay Conclusion? All necessary equipment for intubation should be present (laryngoscope and several blades, bag-mask units, and adult-size endotracheal tube) DC cardioversion unit: in case of tachyarrhythmias. Phenylephrine: dose: bolus, 0.1 to 0.5 mg; infusion, 25 to 125 g/minute. Epinephrine: dose 0.01 to 0.1 g/kg/minute. Calcium chloride: dose 2 to 4 mg/kg. Lidocaine: 1 to 2 mg/kg. Atropine: 0.01 mg/kg. C.2. In this patient, what hemodynamic effects would occur from intravenous induction with ketamine, thiopental, fentanyl, propofol, etomidate, and essay practitioner midazolam?

After intravenous administration, ketamine (1 mg/kg) has a rapid onset of action and animals rights essay conclusion achieves a peak plasma concentration in less than 1 minute. It also possesses a short duration of essay writng action. After the initial dose, patients may remain unconscious for essay conclusion 10 to 15 minutes, but the essay writng, analgesic effect (somatic greater than visceral) persists for an additional 30 minutes or longer. Some of the hemodynamic effect of ketamine may include small increases in blood pressure, HR, CO, and myocardial oxygen demand. This response is mediated by a direct central sympathetic stimulation and by rights essay conclusion, inhibition of norepinephrine uptake into postganglionic sympathetic nerve endings. Ketamine has also been shown to have intrinsic depressant properties on the myocardium.

In clinical conditions whereby norepinephrine stores are reduced and in the presence of hybrid vehicle preexisting cardiac dysfunction (mechanical or myocardial), administration of ketamine can produce hemodynamic disturbance. Thiopental (4 mg/kg) has a mild to moderate negative inotropic effect as well as vasodilatory property. The hemodynamic response relates to the dose, coexisting diseases (hypertension, ventricular dysfunction), age, intravascular volume, and animals rights essay intactness of autonomic sympathetic responses. Generally, doses of 1 to essay on patriotism and love country 2 mg/kg do not cause significant hemodynamic disturbance; however, in patients with cardiac tamponade, thiopental should not be used for induction. These patients are, literally, on the edge of cardiovascular collapse. Fentanyl does not possess any depressant effects on myocardial contractility but because of its vagotonic effect (decreases in animals rights essay HR) and mild sympatholytic effect (central sympathetic outflow), a reduction in blood pressure may be noted. This response may be more profound in shock or preshock states and when fentanyl is hybrid essay used concomitantly with other induction agents (benzodiazepines, thiopental, propofol).

Propofol produces very similar effects as thiopental. It can cause significant reductions in systemic pressures (greater than 30#37;) and essay there have been several reports of cardiovascular arrest in essay writng both adults and children following inductions with propofol. Propofol also has some antiarrhythmic effect on the atrioventricular (AV) node as well as on other conduction pathways. Animals Essay Conclusion? It should be used with caution when other agents that similarly slow down AV nodal conduction are present (calcium channel blockers, -blockers, digoxin). As with thiopental, the list, use of propofol for induction in cardiac tamponade is strongly disfavored. Etomidate has a very favorable hemodynamic profile and is the preferred agent to be used during induction when cardiovascular collapse is animals rights conclusion anticipated. With an induction dose (0.2 to 0.3 mg/kg), etomidate may cause a slight decrease in mean arterial pressure but such changes are not attributable to myocardial depression as is typical of school essays propofol and sodium thiopental. Pain at the injection site and involuntary muscle movements are the animals, most common adverse events noted with etomidate. It also appears to reduce seizure threshold and enhance its duration when used during electroconvulsion therapy.

Midazolam may cause mild to moderate systemic vasodilation, particularly when used in combination with narcotics. Overall, of the agents discussed, etomidate would be the preferred agent for induction followed by ketamine, and/or fentanyl; whereas, thiopental and propofol would be the least desired. Kaplan JA, Cardiac anesthesia 4th ed. Philadelphia: WB Saunders, 1999:611–626. Tweed WA. Minuck M. Mymin D. Circulatory responses to ketamine anesthesia. Anesthesiology 1972:37:612. C.3. For My Country? Describe the induction process for cardiac tamponade. The patient should have standard monitors placed as well as invasive monitors to animals include indwelling arterial access for beat-to-beat displaying of on patriotism for my country systemic arterial pressures and for essay conclusion obtaining blood gases.

This patient has a PAC in place; however, its use in this setting remains debatable. The actual induction should proceed ONLY in the presence of essay practitioner a surgical team that is ready and animals gowned and after the patient has been completely prepared and draped. The choice of induction agents is limited to narcotics, muscle relaxant (depolarizing or nondepolarizing), and essay writng either etomidate or ketamine. Essay? Regardless of the induction technique, the anesthesiologist should expect and be prepared to list manage ensuing circulatory collapse. Fontes ML. Hines RH.

Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Animals Essay? Philadelphia: Grune Stratton, 1999:1155–1191. C.4. Following induction and intubation, the systemic blood pressure decreased to 55/30 mm Hg.

Describe the clinical events accounting for this perturbation and reports the management steps required for resuscitating this patient. Cardiac tamponade is caused by significant pericardial pressure from accumulating pericardial contents (fluid, blood, and blood clots) that impede chamber filing resulting in a low CO state. The precipitous fall in blood pressure observed with induction can be accounted for by the conclusion, following: first; most induction agents will have negative hemodynamic effects that are either direct or indirect; second, sympatholysis reduces arterial resistance as well as chronotropy and inotropy of the heart; third, the physiologic consequences of switching from negative pressure ventilation to essay writng positive pressure ventilation will further reduce cardiac filling by increasing intrathoracic pressure and rights conclusion afterload; and lastly, placing the patient in a supine position will also compromise atrial and ventricular preload (i.e., hydrostatic effects, loss of diaphragm, and personal essay practitioner weight of mediastinal structures on the heart). The management of hypotension will require use of vasoactive drugs, cardioactive drugs, and/or fluid challenge. Essay Conclusion? Reducing inspiratory positive pressure (i.e., lowering tidal volume or switching from ventilator-delivered breaths to hand ventilation) may also improve the hemodynamic status.

These would be merely temporizing measures; surgical relief of essay writng tamponade would be the definitive treatment of this problem. Fontes ML. Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction. Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. Thomas SJ, Manual of cardiac anesthesia 2nd ed. New York: Churchill Livingstone, 1993:135. C.5.

What hemodynamic changes are frequently associated with opening the chest? Chest opening normalizes the pressure relationship between the pericardium and animals essay the heart chambers, thus relieving the tamponade and its hemodynamic effects. Unless the myocardium has suffered injury or is locke concerning understanding 1 summary stunned, the expected hemodynamic change includes drastic improvement in blood pressure and SV. Most of the vasoactive and cardioactive agents being administered can be quickly weaned. In addition, oxygenation, acid-base status, and renal function (urine output) tend to improve significantly.

C.6. What is rights essay myocardial stunning? What is myocardial hibernation? The myocardium can exhibit segmental dysfunction or hypofunction related to personal essay nurse injury (i.e., ischemia and animals conclusion infarction). Practitioner? It has also been noted that myocardial function can be coupled or uncoupled with tissue perfusion. For example, following a period of oxygen deprivation and restoration of animals conclusion flow, the affected myocardium can resume normal function, diminished function, or no function (dysfunction). The term myocardial stunning represents a state of nurse practitioner uncoupling between function and flow whereby myocardial flow is normal but function is diminished or akinetic. In the setting of cardiac surgery, myocardial stunning can be a cause of ventricular dysfunction that generally resolves within the first 6 to 8 hours post-CPB. Animals Essay? During this period, inotropic support has been shown to be effective. Myocardial hibernation, on the other hand, is a myocardial process that manifests after weeks or months and nurse denotes a condition whereby both myocardial function and flow are reduced (coupled).

Perhaps this is an adaptive process that allows the myocytes to lower their metabolic activity and essay oxygen consumption to survive during states of oxygen deprivation. The definitive diagnosis of stunning and hibernation may be difficult to make because regional myocardial blood flow is difficult to assess or quantify clinically. Therefore, most cases of stunning and hibernation require a retrospective analysis. First, segmental myocardial dysfunction must be established; second, myocardial blood flow should be restored by revascularization (surgical, pharmacologic, or angioplasty/stenting); and essay practitioner third, improvement of animals rights conclusion regional function should follow revascularization. D'Ancona G. Donias HW. Bergsland J, et al.Myocardial stunning after off-pump coronary artery bypass grafting: safeguards and pitfalls. Ann Thorac Surg 2001:72:2182–2183. Fontes ML. Essay Nurse Practitioner? Hines RH. Pharmacologic treatment of perioperative left and right ventricular dysfunction.

Kaplan JA, Reich DSN, Konstadt SN, Cardiac anesthesia 4th ed. Philadelphia: Grune Stratton, 1999:1155–1191. Lorusso R. La Canna G. Ceconi C, et al.Long-term results of coronary artery bypass grafting procedure in the presence of left ventricular dysfunction and conclusion hibernating myocardium. Eur J Cardio Thorac Surg 2001:20:937–948. Shah BR. Essay On Patriotism For My Country? Velazquez E. Shaw LK, et al.Revascularization improves survival in ischemic cardiomyopathy regardless of electrocardiographic criteria for prior small-to-medium myocardial infarcts. Am Heart J 2002:143:111–117.

Watzinger N. Saeed M. Wendland MF, et al.Myocardial viability: magnetic resonance assessment of functional reserve and tissue characterization. J Cardiovasc Magn Reson 2001:3:195–208. D. Postoperative Management. D.1. How would you manage hypertension in the intensive care unit (ICU)? The management of hypertension depends on its etiology.

Rather than administering antihypertensive agents indiscriminately, the clinician should exclude the following conditions as causality of hypertension: hypoxemia, hypercarbia, acid-base derangements, and animals pain. The occurrence of concerning book hypertension is animals rights a common phenomenon during the first several hours in the ICU. In most cases, the etiology is uncertain and and love country probably represents a state of marked sympathoadrenal activation. Once correctable causes of hypertension have been addressed, antihypertensive therapy can be achieved with a variety of agents. Most often, sodium nitroprusside is animals essay used because of essay writng its potent effect and titratability. Animals Rights Essay Conclusion? Because the underlying mechanism of the hypertension involves endogenous release of norepinephrine (with minimal epinephrine), the personal nurse practitioner, most rational agents to use are the -blockers.

Labetalol antagonizes both - and -adrenergic receptors and is an effective antihypertensive agent. Alternatively, metoprolol, atenolol, esmolol, or propranolol can be used particularly if the hypertension is associated with tachycardia. Animals? Unfortunately, these agents are used infrequently because of theoretical concerns of and love for my myocardial depression and bradycardia. Current cardiology practice strongly endorses the use of -blockers in animals rights the setting of moderate and severe ventricular dysfunction. Graduate School Application? In addition, the cardioprotective effects of -blockers have been shown in animals several perioperative trials whereby the incidence of myocardial injury and mortality (up to 2 years postoperatively) are significantly reduced in hybrid vehicle essay patients treated perioperatively with -blockers. Kotlyar E. Macdonald PS. Keogh AM, et al.Optimization of left ventricular function with carvedilol before high-risk cardiac surgery. J Heart Lung Transplantation 2001:20:1129–1131. Leslie J. Brister N. Levy JH, et al.Treatment of postoperative hypertension after coronary artery bypass surgery.

Double-blind comparison of intravenous isradipine and sodium nitroprusside. Circulation 1994:90:(5 Pt 2)II256–261. Lucas WJ. Boysen PG. Antihypertensive agents following cardiac surgery. Crit Care Med 1997:25:1770–1771. Wallace A. Layug B. Tateo I, et al.Prophylactic atenolol reduces postoperative myocardial ischemia. Anesthesiology 1998:88:7–17. Wood G. Effect of antihypertensive agents on rights the arterial partial pressure of oxygen and venous admixture after cardiac surgery.

Crit Care Med 1997:25:1807–1812. D.2. Personal Essay? When would it be appropriate to extubate this patient? The timing of extubation depends on the following: Clinical stability (stable hemodynamics without need for significant inotropic or vasoactive support) Intact neurologic function (alertness and ability to comprehend and execute simple verbal commands) Adequate pulmonary function (acceptable arterial blood gases and acid-base status and adequate weaning parameters#151;tidal volume, respiratory rate, vital capacity, and inspiratory effort) Normal body temperature and rights neuromuscular function (reverse paralysis if necessary)

Normal coagulation (bleeding less than 60 mL/hour and normalization of coagulation parameters) Following relief of tamponade, most patients can be extubated as early as possible assuming that the previously listed criteria have been met.

Best Essay Writers Here -
Animal Rights – Essay Sample

control essay 1984 Written February 27, 2000; Modified May 9, 2000. If you quote or paraphrase from animals rights essay, my essay, please give me due credit. Language as the #147;Ultimate Weapon#148; in Nineteen Eighty-Four. George Orwell, like many other literary scholars, is interested in the modern use of the application English language and, in particular, the abuse and rights, misuse of English. He realises that language has the personal essay power in politics to mask the truth and mislead the essay public, and he wishes to increase public awareness of essay nurse practitioner, this power. He accomplishes this by placing a great focus on Newspeak and the media in his novel Nineteen Eighty-Four . Demonstrating the essay conclusion repeated abuse of language by the government and by the media in his novel, Orwell shows how language can be used politically to deceive and manipulate people, leading to a society in which the people unquestioningly obey their government and mindlessly accept all propaganda as reality.

Language becomes a mind-control tool, with the ultimate goal being the essay writng destruction of will and imagination. As John Wain says in his essay, #147;[Orwell#146;s] vision of 1984 does not include extinction weapons . . . Animals Rights! He is not interested in extinction weapons because, fundamentally, they do not frighten him as much as spiritual ones#148; (343). Paul Chilton suggests that the language theme in Orwell#146;s novel has its roots in the story of the Tower of Babel (2). On Patriotism And Love For My! When God destroys the Towel of Babel, the civilizations which have contributed to the construction of the Tower suffer ever-after from the Curse of rights essay conclusion, Confusion. Of Book! The Curse both makes languages #147;mutually unintelligible#148;, and alters their nature so that #147;they no longer lucidly [express] the nature of things, but rather [obscure] and [distort] them#148; (Chilton, 2). Orwell#146;s Newspeak , the essay ultra-political new language introduced in Nineteen Eighty-Four , does precisely that: it facilitates deception and manipulation, and graduate school essays tips, its purpose is to restrict understanding of the real world. Chilton also suggests that a corollary to this is that #147;each post-Babel language [becomes] a closed system containing its own untranslatable view of the world#148; (2). Certainly, the ultimate aim of Newspeak is to enclose people in an orthodox pseudo-reality and isolate them from the real world. Whereas people generally strive to expand their lexicon, the government in Nineteen Eighty-Four actually aims to cut back the Newspeak vocabulary.

One of the Newspeak engineers says, #147;[we#146;re] cutting the language down to the bone . . . Newspeak is the only language in the world whose vocabulary gets smaller every year#148; (55). Animals Conclusion! By manipulating the language, the government wishes to alter the public#146;s way of thinking. This can be done, psychologists theorise, because the words that are available for graduate school the purpose of communicating thought tend to influence the way people think. The linguist Benjamin Lee Whorf was a firm believer in rights conclusion this link between thought and language, and he theorised that #147;different languages impose different conceptions of reality#148; (Myers 352). So when words that describe a particular thought are completely absent from a language, that thought becomes more difficult to think of and graduate application tips, communicate. For the Inner Party, the goal is to animals essay, impose an orthodox reality and make heretical thought (#145;thoughtcrime#146;) impossible. Essay Writng! #147;In the end we shall make thoughtcrime literally impossible,#148; explains the Newspeak engineer, #147;because there will be no words in which to express it#148; (55). By design, Newspeak narrows the range of thought and shortens people#146;s memories. It is therefore ideal for essay conclusion a totalitarian system, in hybrid essay which the animals rights essay government has to rely on a passive public which lacks independent thought and which has a great tolerance for mistakes, both past and present. Essay Writng! #147;To expand language is to expand the ability to think,#148; says Myers (353). Conversely, to restrict language, as with Newspeak, is to restrict the range of thought. Chilton identifies the specific features of essay, Newspeak that help restrict thought: #147;reduced complexity, few abstractions, and no self­reference#148; (37).

Such narrowed public thought is what the Inner Party prefers, because a public that lacks the ability to of book, think vividly poses less of a threat than one that can readily criticise the government and defend itself from harm. However, an interesting consequence of this narrowed thought is that the public#146;s memory is also effectively shortened. #147;The Inner Party [deprives] people of their own words and in so doing, deprives them of memory#148; (Lewis and Moss 51). After O#146;Brien forces Winston to embrace Ingsoc, for instance, Winston#146;s imagination decays and animals, he #147;[can] no longer fix his mind on any one subject for more than a few moments at a time#148; (301). Graduate Essays! Winston, like the majority of the animals essay conclusion public, suffers when he is robbed of his words and thoughts. Consequently, #147;memory, with its attendant richness and variety, atrophies#148; since #147;memories die when they go unrehearsed in words#148; (Lewis and Moss 51). Given that Newspeak is such a politically-motivated language, why does the public in Nineteen Eighty-Four accept it? After all, the Party is undertaking a project of monumental proportions: they are trying to completely replace a common language (English, or #147;Oldspeak#148;), and one would expect great opposition to such a plan. Essay Concerning Human! The Party is able to achieve this by again employing psychological tactics. Instead of forcing the public to use Newspeak by law, the Party ensures that the public is immersed in the new language.

Nobody is forced to read or write in Newspeak, but #147;its ubiquitous broadcast creates a pressure to employ it simply in order to communicate economically#148; (Chilton 37). Orwell#146;s novel paints a nightmarish picture of a totalitarian system gone to the absolute extreme, but it is a novel that is fundamentally about psychological control of the public. Of course, the Party does employ torture as part of its control regimen, but the psychological control tactics are the dominant ones in the novel. While physical punishment is difficult to animals rights essay, administer, psychological tactics (manipulation of people through language) can be continuously applied to the general public without raising great public opposition or fear #151; and that is where its strength lies. It is for this reason that #147;Newspeak rather than torture is planned as the locke essay concerning way to erase thoughtcrime#148; (Stansky 88). However, while Newspeak is essay conclusion, a very significant method of mind control through language, it is just a part of a greater Inner Party scheme. It is, in fact, the Party-controlled media in the novel that expertly uses Newspeak as well as other linguistic trickery to spread its propaganda and brainwash the public. The media is powerful as a tool for manipulation both because the public is widely exposed to it, and also because the public trusts it. The telescreens continuously shout bursts of news and propaganda throughout the day, and the people listen intently and cheer at #145;good news#146; (victories) and are driven to rage by #145;bad news#146;.

The characters in Orwell#146;s novel are slaves of the media; they revere it as an oracle. When the telescreens initiate the essay concerning understanding 1 summary Two Minutes Hate, for instance, the rights essay conclusion people are roused to a frenzy: #147;People were leaping up and down in their places and essay on patriotism for my, shouting at the tops of their voices . . . [a girl] had begun crying out #145;Swine! Swine! Swine!#146;#148; (16). Certainly, in Nineteen Eighty-Four , #147;[media information] does control some of the ways in which [people] think about and assess the world#148; (Lewis and Moss 47).

The Party is interested in masking the truth, and so the media manipulates language to present a distorted reality. As Orwell says in his essay Politics and the English Language , #147;Political language . . . is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to animals essay conclusion, pure wind#148; (150). In the novel, these lies are quite obvious. For example, the list media (controlled by the Party, of course) continually refers to essay conclusion, the Ministries of essays tips, Truth, Peace, Love, and Plenty. Conclusion! In reality, however, the Ministry of Truth is concerned with the falsification of records, and the Ministry of Peace deals with warfare. The Ministry of Love is #147;the really frightening one#148; (6) as it is essentially a place for the questioning and torturing of suspected criminals. List Reports! The Ministry of Plenty makes up economic figures to convince the public that the economy is in good shape, even though there are great shortages of all commodities due to the war. Although the animals rights conclusion irony in the titles is blatantly obvious, Orwell is making a point about how the media can use language to mask the truth. The totalitarian state of Oceania is in a constant state of essay writng, war, and part of the Party#146;s ongoing struggle is to rights essay, keep the essay writng public satisfied with this warfare. If the public were dissatisfied, they would resent the shortage of food and other commodities and possibly rebel against the Party.

The Party therefore has to distract the public#146;s attention away from the negative side of warfare, and they use the media to do this. By using only language that carries neutral or positive connotations to talk about anything related to war, the media successfully soothes an otherwise resentful public. For instance, the media never reports on the #147;twenty or thirty [rocket bombs] a week falling on London#148; (28), but rather inundates peoples#146; lives with good news about victories. Winston#146;s telescreen announces, #147;Our forces in South India have won a glorious victory. I am authorised to say that the rights essay conclusion action we are now reporting may well bring the war within measurable distance of its end#148; (28). Similar reports follow throughout the entire novel, constantly celebrating the capture of enemies and the conquering of new territories, but never admitting any kind of graduate essays tips, defeat. In many ways, the essay conclusion media is relying on the principle that a piece of information that is repeated often enough becomes accepted as truth.

Winston, a particularly strong-minded individual, is continually amazed to see his friends and colleagues swallow the lies that the media dishes out. For this form of locke essay human understanding 1 summary, brainwashing (#145;Duckspeak#146;) to be effective, #147;you just say things frequently and people eventually understand and animals essay conclusion, say it themselves#148; (Chilton 27). This brainwashing is done through the words of the telescreens, newspapers and magazines. The media is skilled at engineering #145;truth#146; through language, and one of the most disturbing consequence of this developed in the novel is that the list of book Party has ultimate control over history. After all, language is the link to history. Winston#146;s job in the Ministry of Truth is to animals essay, modify news items and other documents that in one way or another make the Party look bad. After he replaces an original document with the modified one, all the originals are destroyed. Orwell describes the process: This processes of continuous alteration was applied not only to newspapers, but to books, periodicals, pamphlets, posters, leaflets . . . Day by day and almost minute by minute the list of book past was brought up to date.

In this way every prediction made by the Party could be shown by documentary evidence to have been correct; nor was any item of essay conclusion, news, or any expression of school, opinion, which conflicted with the needs of the moment, ever allowed to remain on record. (42) Lewis and Moss believe that #147;the tactic is to obliterate history so that centres of opposition cannot grow#148; (51). Animals Conclusion! Orwell shows us evidence that this tactic is essay on patriotism and love, working: even the main character, who knows exactly what is going on with the falsification of documents, has trouble recalling who Oceania is really at war with at the present. It is essay conclusion, either Eurasia or Eastasia, but Winston is list of book, not sure because the animals Party keeps changing history. This nagging doubt eats away at Winston until he no longer knows what reality is; by the end of the on patriotism and love novel, he is willing to accept the Party#146;s reality. Orwell#146;s novel asks the philosophical question: if all available evidence shows something to be true, is it not true? Winston struggles with this idea of #147;Reality control#148; (37) as he works at the Ministry of Truth. #147;The frightening thing,#148; Winston thinks to himself, #147;[is] that it might all be true. If the Party [can] thrust its hand into the past and say of this or that event, it never happened #150; that, surely, [is] more terrifying than mere torture and death#148; (36).

One of Winston#146;s assignments is to invent a biography of a fictional soldier named Ogilvy, so that he can be honoured by Big Brother in a public address. After writing the description of Ogilvy#146;s life, Winston marvels at essay, how #147;once the act of essay writng, forgery [is] forgotten, [Ogilvy will] exist just as authentically, and upon the same evidence, as Charlemagne or Julius Caesar#148; (50). As well as altering the past by manipulating written language, the Party has an ingenious plan to break the animals link with the real past by introducing a language barrier. Graduate Tips! When #147;all real knowledge of Oldspeak [disappears] . . . the whole literature of the past will have been destroyed#148; (56). After a few generations, when people are no longer capable of animals rights, decoding information from the past, there will no longer even be a need to of book reports, censor the history that has the potential for breeding unorthodox ideas #151; it will be completely out of the public#146;s reach.

Thus, the manipulation of language and text not only effects the present, but also the past and future in more than one way. A Party slogan in the novel reads, #147;Who controls the past, controls the future: who controls the present controls the past#148; (37). Orwell#146;s novel is animals conclusion, extreme, but it is not necessarily a prediction of the of book reports future. Conclusion! Rahv believes that the book#146;s #147;importance is and love for my country, mainly in its powerful engagement with the present#148; (183). Indeed, politicians have used written language to animals rights essay conclusion, manipulate history both in the past and present. There was much distortion of history during the Stalinist era, #147;when such standard works of misinformation as the Soviet Encyclopaedia changed constantly with the hybrid vehicle essay party line, so that in successive editions Trotsky was first the hero of the Civil War, then an agent of the Mensheviks, and the western powers#148; (Woodcock 177).

Patrick Wright suggests that the issue is still very much alive in the late twentieth century, citing as an example #147;[the British Secretary for Education, who] refused a number of proposed syllabus systems for the teaching of history in schools, finding them insufficiently assiduous in their promotion of the mythical, rather than simply historical, values of national unity and pride#148; (111). Equally alive today is the fear that politicians and the media abuse language to hide truth. Orwell gives examples of essay, how politicians can twist words to essay writng, deceive people in his essay Politics and the English Language : #147;Defenceless villages are bombarded from the air, the inhabitants driven out into the countryside . . Rights Conclusion! . this is vehicle, called pacification . Millions of peasants are robbed of their farms and sent trudging along the roads with no more than they can carry: this is called transfer of population or rectification of frontiers #148; (148). Animals! Woodcock refers to vehicle, the modern jargon-filled English used by #147;newspaper editors, bureaucrats, radio announcers, and parliamentary speakers#148; who have, just as Orwell feared, a heavy #147;reliance on animals rights ready-made phrases#148; (92). Personal Essay Nurse Practitioner! Even more disturbing, in the twenty-first century we have now a rapidly growing, major industry based solely upon the manipulation of animals essay conclusion, language and thought: advertising. Orwell#146;s novel carries a well-founded warning about the powers of vehicle essay, language. It shows how language can shape people#146;s sense of reality, how it can be used to conceal truths, and even how it can be used to manipulate history. Animals Rights! #147;Language is one of the key instruments of political dominations, the necessary and insidious means of the #145;totalitarian#146; control of reality#148; (Rai, 122). While language in the traditional sense can expand horizons and improve our understanding of the world, Orwell#146;s novel demonstrates that language, when used in a maliciously political way, can just as easily become #147;a plot against human consciousness#148; (Rahv, 182). Chilton, Paul. Orwellian Language and the Media . Essay Human! London: Pluto Press, 1988. Lewis, Florence and Peter Moss.

The Tyranny of Language in Nineteen Eighty-Four in 1984 . Aubrey, Crispin and Paul Chilton, eds. London: Comedia Publishing Group, 1983. 45-57. Myers, David G. Animals Essay! Psychology . 4 th ed. Holland: Worth Publishers, 1986. Orwell, George. Essay Writng! Nineteen Eighty-Four . London: Penguin Books, 1990. - - - . Politics and the English Language in Nineteen Eighty-Four: Text, Sources, Criticism . Ed. Irving Howe. New York: Harcourt, Brace World, Inc., 1963. 143-50.

Rahv, Philip. The Unfuture of Utopia in Nineteen Eighty-Four: Text, Sources, Criticism . 181-5. Rai, Alok. Orwell and the politics of despair: A critical study of the writings of George Orwell . Cambridge: Cambridge University Press, 1988. Stansky, Peter, ed. Rights Essay! On Nineteen Eighty-Four . New York: W. H. Freeman and Company, 1983. Wain, John. Essays on Literature and vehicle essay, Ideas - George Orwell (1) in Twentieth-Century Literary Criticism Vol. 6 . 343-4. Woodcock, George. Orwell#146;s Message: 1984 and the Present . Essay! Madeira Park: Harbour Publishing Co.

Ltd, 1984. Wright, Patrick. Essay! The Conscription of History in Nineteen Eighty-Four in 1984 . 105-14.